When do you hold Tresiba (insulin degludec) in patients with diabetes?

When to Hold Tresiba (Insulin Degludec)

Hold Tresiba during times of prolonged fasting, surgery, or critical medical illness when patients are at greater risk for ketosis, and consider withholding during acute illness that results in weight loss, anorexia, or inconsistent eating patterns. 1

Specific Clinical Situations Requiring Tresiba Hold or Dose Reduction

Perioperative Management

• Administer 60-80% of the usual degludec dose on the day of surgery rather than holding completely, as this maintains basal insulin coverage while reducing hypoglycemia risk 2
• For general surgical procedures, give 75-80% of the usual long-acting insulin dose based on clinical judgment and diabetes type 1
• Monitor blood glucose at least every 2-4 h while the patient takes nothing by mouth and dose with short- or rapid-acting insulin as needed 1

Acute Illness and Critical Care

• Withhold Tresiba during prolonged fasting, surgery, or critical medical illness when patients are at greater risk for ketosis 1
• Hold during acute illness resulting in weight loss, anorexia, short-term cognitive decline, and/or loss of physical functioning 1
• Consider holding if the patient has an inconsistent eating pattern or is unable to maintain adequate oral intake 1

Hypoglycemia Management

• Reduce dose by 10-20% if hypoglycemia occurs, after determining the underlying cause 3
• Hold or reduce dose if severe or recurrent hypoglycemia occurs, regardless of A1C level 1
• If more than 2 fasting glucose values per week are less than 80 mg/dL, decrease the basal insulin dose by 2 units 4

End-of-Life and Palliative Care

• For dying patients with type 2 diabetes, discontinuation of all medications including Tresiba may be reasonable, as patients are unlikely to have any oral intake 1
• For type 1 diabetes patients at end of life, a small amount of basal insulin may be maintained to prevent acute hyperglycemic complications, though there is no consensus 1
• Hold if there is pain or discomfort caused by treatment (e.g., injections) or excessive caregiver stress due to treatment complexity 1

Special Populations Requiring Dose Adjustment or Holding

Older Adults and Frail Patients

• Consider deintensification or deprescribing in older adults with complex/intermediate health status who experience severe or recurrent hypoglycemia 1
• For very complex/poor health patients (long-term care, end-stage chronic illness, moderate to severe cognitive impairment), hold if the individual has an inconsistent eating pattern or if taking medications without clear benefits 1

Patients with Changing Clinical Status

• Hold or reduce dose if there is a significant change in social circumstances, such as loss of caregiver, change in living situation, or financial difficulties 1
• Reduce dose if cognitive or functional decline occurs following acute illness 1
• Consider holding if wide glucose excursions are observed despite appropriate dosing 1

Common Pitfalls to Avoid

• Do not completely discontinue basal insulin in type 1 diabetes patients, even during acute illness or surgery, as this can precipitate diabetic ketoacidosis 1
• Avoid holding Tresiba without a clear plan for alternative glucose management, particularly in hospitalized patients 1
• Do not delay dose reduction when hypoglycemia occurs; act promptly to prevent severe episodes 3
• For patients on enteral/parenteral feeding, adjust rather than hold Tresiba when feeding is interrupted, as complete cessation may lead to hyperglycemia 2