What is the administration and dosing protocol for Tresiba (insulin degludec)?

Tresiba (Insulin Degludec) Administration and Dosing Protocol

Administration Instructions

Inject Tresiba subcutaneously once daily into the thigh, upper arm, or abdomen, rotating injection sites within the same region to prevent lipodystrophy. 1

Key Administration Points:

• Always verify the insulin label before injection to prevent medication errors, as accidental mix-ups between insulin products can cause severe hypoglycemia 1
• Use only if the solution appears clear and colorless upon visual inspection 1
• Never transfer Tresiba from the pen into a syringe, as this can result in overdosage and severe hypoglycemia 1
• Do not administer intravenously, via insulin pump, or mix with other insulins 1
• Rotate injection sites within the same anatomical region (not between different regions) to reduce lipodystrophy and localized cutaneous amyloidosis risk 1
• Avoid injecting into areas with pits, lumps, thickening, tenderness, bruising, or scar tissue 1

Dosing Protocol

Available Formulations:

• U-100 concentration: 10 mL vial and 3 mL FlexTouch pen (delivers 1-unit increments, up to 80 units per injection) 1
• U-200 concentration: 3 mL FlexTouch pen (delivers 2-unit increments, up to 160 units per injection) 1
• No dose conversion needed when using either pen—the dose window shows actual units to deliver 1

Timing Flexibility:

Adults can inject Tresiba once daily at any time of day, with flexibility to vary injection timing day-to-day. 1, 2 This unique feature distinguishes Tresiba from other basal insulins, which require fixed daily timing. The ultra-long half-life (exceeding 25 hours) and flat pharmacodynamic profile allow for injection time variations of 8-40 hours between doses without compromising glycemic control 2, 3.

Pediatric patients (≥1 year) must inject once daily at the same time every day. 1 For pediatric patients requiring less than 5 units daily, use only the U-100 vial 1.

Missed Dose Management:

• Adults: Inject during waking hours upon discovering the missed dose, ensuring at least 8 hours elapse between consecutive injections 1
• Pediatric patients: Contact healthcare provider for guidance and increase blood glucose monitoring frequency until next scheduled dose 1

Initial Dosing

Insulin-Naïve Patients:

• Type 1 diabetes: Must use concomitantly with short-acting prandial insulin 1
• Starting dose: 10 units once daily OR 0.1-0.2 units/kg/day 4

Patients Switching from Other Insulins:

• From once-daily basal insulin: Convert unit-to-unit 4
• From twice-daily NPH or basal insulin: Reduce total daily basal dose by approximately 20% (use 80% of previous total daily dose) 4

Dose Titration

Titrate based on fasting plasma glucose (FPG) using an evidence-based algorithm: increase by 2 units every 3-4 days to reach FPG target without hypoglycemia. 4, 1

Titration Guidelines:

• Recommended interval between dose adjustments: 3-4 days 1
• Target FPG: Individualized based on patient characteristics (typically 90-150 mg/dL for older adults) 4
• For hypoglycemia: Determine cause; if unclear, reduce dose by 10-20% 4
• Monitor for overbasalization: Signs include basal dose >0.5 units/kg/day, elevated bedtime-to-morning glucose differential, hypoglycemia, or high glucose variability 4

Special Populations

Older Adults:

Consider simplifying complex insulin regimens by converting to once-daily basal insulin (using 70% of total previous insulin dose) administered in the morning. 4 This approach reduces injection burden while maintaining glycemic control in older adults with type 2 diabetes.

Renal/Hepatic Impairment:

Dose adjustments may be necessary with changes in renal or hepatic function to minimize hypoglycemia or hyperglycemia risk 1.

Critical Safety Considerations

• Never share pens, syringes, or needles between patients, even with needle changes, due to infection risk 1
• Increase blood glucose monitoring frequency during any insulin regimen changes 1
• Consider glucagon prescription for emergency hypoglycemia treatment 4
• Monitor for hypoglycemia risk factors: Changes in physical activity, meal patterns, concomitant medications, or acute illness 1
• Assess for cardiovascular risk: While Tresiba demonstrates similar efficacy to insulin glargine with lower nocturnal hypoglycemia rates 5, 3, early meta-analyses raised questions about cardiovascular events that require ongoing monitoring 6, 7

Combination Therapy

If A1C remains above target on basal insulin alone, consider adding GLP-1 receptor agonists before intensifying to prandial insulin. 4 Fixed-ratio combinations (IDegLira: insulin degludec/liraglutide) are available and may simplify regimens 4.