Tresiba FlexTouch: Role in Insulin Therapy
Tresiba (insulin degludec) FlexTouch is an ultra-long-acting basal insulin analogue that serves as a once-daily basal insulin option for both type 1 and type 2 diabetes, offering similar glycemic control to insulin glargine but with significantly lower rates of nocturnal hypoglycemia and unique flexibility in dosing timing. 1, 2
Key Pharmacologic Properties
Insulin degludec has distinct pharmacokinetic advantages that differentiate it from other basal insulins:
- Duration of action exceeds 42 hours with a flat, stable, "peakless" glucose-lowering profile 1, 2
- Lower within-patient day-to-day variability in glucose-lowering effect compared to insulin glargine 1
- Reaches maximum concentration at 10-12 hours with a half-life of 17-21 hours, roughly double that of insulin glargine 3
- Available in concentrated formulations: U-200 degludec allows higher basal insulin doses per volume, which may improve convenience and adherence for patients requiring large insulin doses 4
Clinical Positioning in Treatment Algorithms
As Initial Basal Insulin
When initiating insulin therapy in type 2 diabetes:
- Start with 10 units or 0.1-0.2 units/kg body weight once daily, typically used with metformin 4
- Titrate by 10-15% or 2-4 units once or twice weekly until fasting blood glucose targets are met 4
- Degludec is listed alongside NPH, glargine, and detemir as appropriate basal insulin options 4
Advantages Over Other Basal Insulins
Degludec achieves similar glycemic control (HbA1c targets) as insulin glargine but with significantly lower risk of nocturnal hypoglycemia 1, 2. This makes it particularly valuable for:
- Patients at high risk for hypoglycemia (elderly, those with chronic kidney disease) 4
- Patients with unpredictable schedules who struggle with rigid insulin timing 5, 2
- Those requiring large basal insulin doses (U-200 formulation available) 4
Flexible Dosing Schedule
A unique advantage: Degludec tolerates day-to-day variation in dose timing while maintaining efficacy and low nocturnal hypoglycemia risk 5, 2. This addresses a major barrier to insulin adherence, as surveys indicate patients with diabetes sometimes omit doses due to scheduling rigidity 5.
Role in Combination Injectable Therapy
When basal insulin alone fails to achieve HbA1c targets (or dose exceeds 0.5 units/kg/day):
Fixed-Ratio Combination Product
Insulin degludec plus liraglutide (IDegLira) is an FDA-approved once-daily fixed dual-combination product that combines basal insulin with a GLP-1 receptor agonist 4. This combination:
- Provides potent glucose-lowering with less weight gain and hypoglycemia compared to intensified insulin regimens 4
- Demonstrated greater durability of glycemic effect compared to basal insulin alone 4
- Allows for simplification of complex insulin regimens 4
Premixed Formulation
70/30 degludec/aspart mix is available for once- or twice-daily dosing before meals 4. This option:
- Provides both basal and prandial coverage in a single injection
- Was noninferior to insulin detemir in type 1 diabetes 1
- May be appropriate for initiating insulin therapy in type 2 diabetes inadequately controlled on oral agents 1
FlexTouch Delivery Device
The FlexTouch prefilled pen is specifically designed for degludec delivery:
- No push-button extension at any dose and low activation force improve ease of use 6
- Rated significantly higher for ease of teaching and learning compared to KwikPen and SoloStar devices (p < 0.001) 6
- Preferred by ≥95% of patients and healthcare professionals for teaching and learning 6
- Available only in prefilled pens (not vials) to minimize dosing errors 4
- FlexTouch with degludec 200 units/mL is recommended for most patients with type 2 diabetes; 100 units/mL cartridges are available for patients requiring smaller doses, including most with type 1 diabetes 2
Important Clinical Considerations
When to Maintain Metformin
Continue metformin when initiating combination injectable therapy with degludec 4. Sulfonylureas and DPP-4 inhibitors are typically discontinued when advancing beyond basal insulin alone 4.
Cost Considerations
While degludec offers clinical advantages (reduced nocturnal hypoglycemia, flexible timing), NPH insulin remains a more affordable basal insulin option for patients with cost constraints, despite causing more hypoglycemia 4. The concentrated U-200 formulation may be more expensive than U-100 insulins 4.
Dose Titration Remains Critical
Once any insulin regimen is initiated, timely dose titration is essential based on blood glucose levels and understanding of each formulation's pharmacodynamic profile 4.