What is the recommended use and dosing of Degludec (Insulin Degludec) for diabetes mellitus?

Insulin Degludec: Recommended Use and Dosing

Indications

Insulin degludec (Tresiba) is indicated for improving glycemic control in patients 1 year of age and older with type 1 or type 2 diabetes mellitus, administered as a once-daily basal insulin. 1

• In type 1 diabetes, degludec must be used concomitantly with short-acting (prandial) insulin 1
• In type 2 diabetes, degludec can be used alone or combined with oral antidiabetic agents or GLP-1 receptor agonists 2
• Not recommended for diabetic ketoacidosis 1

Starting Doses in Insulin-Naïve Patients

Type 1 Diabetes

• Start with one-third to one-half of the total daily insulin dose as degludec 1
• The remainder should be administered as short-acting insulin divided between meals 1
• As a general rule, calculate initial total daily insulin dose as 0.2 to 0.4 units/kg body weight 1

Type 2 Diabetes

• Start with 10 units once daily 1
• This is the standard FDA-approved starting dose for insulin-naïve patients 1

Switching from Other Insulins

Adults (Type 1 or Type 2)

• Start degludec at the same unit dose as the total daily long- or intermediate-acting insulin 1

Pediatric Patients (≥1 year old)

• Start degludec at 80% of the total daily long- or intermediate-acting insulin dose to minimize hypoglycemia risk 1

Administration Guidelines

Timing and Frequency

• Adults: Once daily at any time of day (flexible timing allowed) 1
• Pediatric patients: Once daily at the same time every day (consistent timing required) 1
• If adults miss a dose, inject during waking hours upon discovery, ensuring at least 8 hours between consecutive injections 1
• If pediatric patients miss a dose, contact healthcare provider for guidance and increase glucose monitoring 1

Injection Technique

• Inject subcutaneously into thigh, upper arm, or abdomen 1
• Rotate injection sites within the same region to reduce lipodystrophy risk 1
• Do NOT inject into areas of lipodystrophy or localized cutaneous amyloidosis 1

Available Formulations

U-100 Concentration

• FlexTouch pen: Delivers 1-unit increments, up to 80 units per injection 1
• 10 mL vial: For pediatric patients requiring <5 units daily 1

U-200 Concentration

• FlexTouch pen: Delivers 2-unit increments, up to 160 units per injection 1
• No dose conversion needed—the dose window shows actual units to deliver 1
• Allows higher doses per volume for patients requiring large insulin amounts 2

Dose Titration

• Titrate every 3 to 4 days based on metabolic needs, glucose monitoring, and glycemic goals 1
• Adjust doses with changes in physical activity, meal patterns, renal/hepatic function, or acute illness 1
• The American Diabetes Association recommends increasing by 10-15% or 2-4 units once or twice weekly until fasting glucose targets are met 3

Treatment Intensification

When Basal Insulin Alone Is Insufficient

If basal insulin dose exceeds 0.5 units/kg/day and A1C remains above target, advance to combination injectable therapy rather than continuing to escalate degludec alone 2, 3

Options include:

• Adding a GLP-1 receptor agonist (associated with weight loss and less hypoglycemia) 2
• Adding prandial insulin starting with 4 units or 10% of basal dose at the largest meal 2
• FDA-approved fixed-ratio combinations: liraglutide plus degludec 2
• Switching to twice-daily premixed insulin (70/30 degludec/aspart) 2

Critical Safety Warnings

Absolute Contraindications

• Never share pens, needles, or syringes between patients (blood-borne pathogen risk) 1
• Do NOT administer intravenously or via insulin pump 1
• Do NOT dilute or mix with any other insulin or solution 1
• Do NOT transfer from pen to syringe 1

Hypoglycemia Risk

• Hypoglycemia is the most common adverse reaction 1
• Clinical trials demonstrate degludec has significantly lower nocturnal hypoglycemia rates compared to insulin glargine 4, 5, 6
• When adding significant prandial insulin doses (especially with evening meals), consider decreasing basal insulin 2

Monitoring Requirements

• Increase blood glucose monitoring frequency during any insulin regimen changes 1
• Patients injecting repeatedly into lipodystrophy areas should change to unaffected sites and closely monitor for hypoglycemia 1

Clinical Advantages

Degludec provides ultra-long duration of action (>42 hours) with a flat, peakless profile and less day-to-day variability than insulin glargine 4, 6, 7

• Flexible dosing in adults allows day-to-day variation in injection timing without compromising efficacy or safety 8, 6
• Particularly suited for patients with unpredictable schedules, frequent travelers, or those finding rigid scheduling burdensome 8
• Noninferior to glargine for achieving A1C <7% with lower nocturnal hypoglycemia risk 4, 5

Special Populations

• For patients requiring >200 units daily, consider U-500 regular insulin instead 3
• U-200 degludec formulation allows higher doses per volume for insulin-resistant patients 2, 1
• Dose adjustments needed during puberty, pregnancy, and acute illness 3