Tresiba (Insulin Degludec) Initial Dosing
For insulin-naive patients with type 2 diabetes, start Tresiba at 10 units once daily; for type 1 diabetes, start at approximately one-third to one-half of the total daily insulin dose (with the remainder as short-acting insulin at meals), using 0.2-0.4 units/kg as the initial total daily insulin calculation. 1
Type 2 Diabetes Initial Dosing
The FDA-approved starting dose for insulin-naive type 2 diabetes patients is 10 units once daily. 1 This aligns with general basal insulin initiation guidelines that recommend 10 units or 0.1-0.2 units/kg body weight once daily. 2, 3
Dose Titration Protocol
- Increase the dose by 2-4 units (or 10-15%) every 3-4 days until fasting blood glucose reaches 80-130 mg/dL. 3, 1
- The FDA recommends 3-4 days between dose adjustments. 1
- For fasting glucose ≥180 mg/dL, increase by 4 units every 3 days. 3
- For fasting glucose 140-179 mg/dL, increase by 2 units every 3 days. 3
Timing Flexibility
Unlike other basal insulins, Tresiba can be administered at any time of day in adults (though pediatric patients require same-time dosing). 1 This unique flexibility stems from its ultra-long duration of action exceeding 42 hours. 4, 5 If a dose is missed, adults should inject during waking hours ensuring at least 8 hours between consecutive injections. 1
Type 1 Diabetes Initial Dosing
For insulin-naive type 1 diabetes patients, start Tresiba at approximately one-third to one-half of the total daily insulin dose, with the remainder given as short-acting insulin divided among meals. 1
Calculating Total Daily Dose
- Use 0.2-0.4 units/kg body weight to calculate initial total daily insulin dose. 1
- For a 70 kg patient, this equals 14-28 units total daily, with approximately 5-14 units as Tresiba and the remainder as mealtime rapid-acting insulin. 1
- Tresiba must always be used with short-acting insulin in type 1 diabetes. 1
Switching from Other Insulins
From Long-Acting or Intermediate-Acting Insulin
- Adults: Start Tresiba at the same unit dose as the previous total daily long or intermediate-acting insulin. 1
- Pediatric patients (≥1 year): Start at 80% of the previous total daily long or intermediate-acting insulin dose to minimize hypoglycemia risk. 1
Severe Hyperglycemia Situations
For patients with HbA1c ≥9%, blood glucose ≥300-350 mg/dL, or symptomatic/catabolic features, consider higher starting doses of 0.3-0.4 units/kg/day. 3
Critical Formulation Considerations
Tresiba is available in two concentrations that require different handling:
- U-100: Available as FlexTouch pen (delivers 1-80 units) and 10 mL vial. 1
- U-200: Available only as FlexTouch pen (delivers 2-160 units in 2-unit increments). 1
Do NOT perform dose conversion between concentrations—the dose window shows actual units to deliver. 1 For pediatric patients requiring less than 5 units daily, use only the U-100 vial. 1
Absolute Contraindications to Administration
Never administer Tresiba:
- Intravenously or via insulin pump. 1
- Mixed or diluted with any other insulin or solution. 1
- Transferred from pen to syringe. 1
These restrictions differ from older insulins and are critical safety considerations. 1
When to Add Prandial Insulin
If after 3-6 months of optimized basal insulin (fasting glucose 80-130 mg/dL) the HbA1c remains above goal, or when basal insulin approaches 0.5-1.0 units/kg/day without achieving targets, add prandial insulin rather than continuing to escalate Tresiba. 3 Start with 4 units of rapid-acting insulin before the largest meal or 10% of the basal dose. 3
This prevents "overbasalization"—a common pitfall where excessive basal insulin causes hypoglycemia without adequately controlling postprandial glucose. 3
Monitoring Requirements
- Daily fasting blood glucose monitoring is essential during titration. 3
- Reassess every 3 days during active titration and every 3-6 months once stable. 3
- If hypoglycemia occurs, reduce the dose by 10-20%. 3
Special Population Considerations
Lower starting doses (0.1-0.25 units/kg/day) are recommended for: