What is the recommended dosing and treatment plan for insulin degludec (insulin degludec) in patients with type 1 and type 2 diabetes?

Insulin Degludec Dosing and Treatment Plan for Type 1 and Type 2 Diabetes

For patients with type 1 and type 2 diabetes, insulin degludec should be administered subcutaneously once daily at any time of day for adults, while pediatric patients should receive it at the same time each day, with initial dosing of 10 units daily for insulin-naïve type 2 diabetes patients and one-third to one-half of the total daily insulin dose for type 1 diabetes patients. 1

General Dosing Guidelines

• Insulin degludec is available in two concentrations: U-100 (available as FlexTouch pen and multiple-dose vial) and U-200 (available as FlexTouch pen only) 1
• The U-100 FlexTouch pen delivers doses in 1-unit increments up to 80 units per injection, while the U-200 FlexTouch pen delivers doses in 2-unit increments up to 160 units per injection 1
• No dose conversion is needed when using the FlexTouch pens as the dose window shows the number of insulin units to be delivered 1
• Dose titration should occur every 3-4 days based on blood glucose monitoring results and glycemic targets 1

Type 1 Diabetes Dosing

• For insulin-naïve patients with type 1 diabetes, the recommended starting dose is approximately one-third to one-half of the total daily insulin dose 1
• The remainder of the total daily insulin dose should be administered as short-acting insulin divided between meals 1
• As a general rule, 0.2 to 0.4 units of insulin per kilogram of body weight can be used to calculate the initial total daily insulin dose 1
• For patients switching from another basal insulin, pediatric patients should start at 80% of the previous total daily long or intermediate-acting insulin dose to minimize hypoglycemia risk 1
• Adult patients switching from another basal insulin can start at the same unit dose as their previous total daily long or intermediate-acting insulin 1
• Insulin degludec must be used concomitantly with short-acting insulin in patients with type 1 diabetes 1

Type 2 Diabetes Dosing

• For insulin-naïve patients with type 2 diabetes, the recommended starting dose is 10 units once daily 1
• For patients already on insulin therapy, adults can start at the same unit dose as their previous total daily long or intermediate-acting insulin 1
• Pediatric patients switching from another basal insulin should start at 80% of their previous total daily long or intermediate-acting insulin dose 1
• When basal insulin has been titrated to an acceptable fasting blood glucose but HbA1c remains above target, consider advancing to combination injectable therapy 2

Special Considerations

• Insulin degludec has demonstrated a lower risk of nocturnal hypoglycemia compared to insulin glargine in both type 1 and type 2 diabetes 3, 4
• For patients who experience frequent severe hypoglycemia with human insulin, long-acting insulin analogues like insulin degludec should be considered 2
• Insulin degludec provides uniform "peakless" action that extends over more than 24 hours and is highly consistent from dose to dose 5
• For adult patients who miss a dose, they should inject their daily dose during waking hours upon discovering the missed dose, ensuring at least 8 hours between consecutive injections 1
• For pediatric patients who miss a dose, they should contact their healthcare provider for guidance and monitor blood glucose levels more frequently until the next scheduled dose 1

Combination Therapy Options

• In type 2 diabetes, if basal insulin alone is insufficient, combination with a GLP-1 receptor agonist can be considered before advancing to multiple daily injections 2
• Fixed combination products containing insulin degludec plus liraglutide (IDegLira) are available and may simplify treatment 2, 6
• When initiating combination injectable therapy, metformin therapy should be maintained, while sulfonylureas and DPP-4 inhibitors are typically discontinued 2
• For patients requiring complex insulin regimens, adjunctive use of SGLT2 inhibitors may help improve control and reduce insulin requirements 2, 7

Practical Implementation and Monitoring

• Dose adjustments may be needed with changes in physical activity, meal patterns, renal or hepatic function, or during acute illness to minimize hypoglycemia or hyperglycemia risk 1
• Regular monitoring of blood glucose is essential for dose titration and optimization 1
• Insulin degludec should never be administered intravenously or in an insulin infusion pump 1
• Do not dilute or mix insulin degludec with any other insulin or solution 1
• Insulin degludec is contraindicated during episodes of hypoglycemia and in patients with hypersensitivity to insulin degludec or any of its excipients 1

Clinical Outcomes

• In clinical trials, insulin degludec was non-inferior to insulin glargine with respect to HbA1c reduction at 52 weeks in both type 1 and type 2 diabetes 3
• At similar levels of glycemic control, insulin degludec was associated with lower rates of hypoglycemia than insulin glargine 3, 4
• In type 1 diabetes, nocturnal confirmed hypoglycemia was 25% lower with insulin degludec compared to insulin glargine 3
• In type 2 diabetes, overall confirmed hypoglycemia was 18% lower and nocturnal confirmed hypoglycemia was 25% lower with insulin degludec 3
• Observational studies in routine clinical practice have shown that insulin degludec can maintain glycemic control at a lower insulin dose and frequency of hypoglycemia in type 1 diabetes, while improving glycemic control at equal insulin doses in type 2 diabetes 8