How do I adjust Tresiba (insulin degludec) dosing for optimal glycemic control?

Adjusting Tresiba (Insulin Degludec) for Optimal Glycemic Control

Start Tresiba at 10 units once daily for insulin-naïve type 2 diabetes patients, or at 0.1-0.2 units/kg/day, then increase by 2 units every 3-4 days if fasting glucose is 140-179 mg/dL, or by 4 units every 3-4 days if fasting glucose ≥180 mg/dL, until reaching a target of 80-130 mg/dL. 1, 2

Initial Dosing Strategy

Type 2 Diabetes (Insulin-Naïve)

• Begin with 10 units once daily at any time of day (adults have flexibility in timing, but pediatric patients must use the same time daily) 1, 2
• Alternative weight-based approach: 0.1-0.2 units/kg/day for standard hyperglycemia 2, 1
• For severe hyperglycemia (A1C ≥9%, glucose ≥300-350 mg/dL): consider 0.3-0.4 units/kg/day or immediate basal-bolus regimen 2, 3
• Continue metformin unless contraindicated 2, 3

Type 1 Diabetes (Insulin-Naïve)

• Start with one-third to one-half of total daily insulin dose as Tresiba 1
• Total daily insulin typically ranges 0.4-1.0 units/kg/day, with approximately 50% as basal insulin 2, 4
• The remainder must be given as short-acting insulin divided among meals 1, 2

Evidence-Based Titration Algorithm

Standard Titration Schedule

• Increase by 2 units every 3-4 days if fasting glucose is 140-179 mg/dL 1, 2, 4
• Increase by 4 units every 3-4 days if fasting glucose ≥180 mg/dL 2, 4
• Maintain current dose if fasting glucose is 80-130 mg/dL 2, 4
• Decrease by 2 units if more than 2 fasting values per week are <80 mg/dL 2, 4
• Reduce dose by 10-20% immediately if hypoglycemia occurs 2, 4

Unique Tresiba Considerations

• Adults can inject at any time of day (unlike other basal insulins requiring consistent timing), but ensure at least 8 hours between consecutive injections if a dose is missed 1
• Pediatric patients must inject at the same time every day 1
• The recommended interval between dose adjustments is 3-4 days (slightly longer than some other insulins due to ultra-long action) 1

Switching to Tresiba from Other Insulins

From Other Basal Insulins

• Adults: Start at the same unit dose as previous long/intermediate-acting insulin 1
• Pediatric patients (≥1 year): Start at 80% of previous basal insulin dose to minimize hypoglycemia risk 1
• Monitor closely during transition and increase glucose monitoring frequency 1

Critical Threshold: When to Stop Escalating Basal Insulin

When Tresiba exceeds 0.5 units/kg/day and approaches 1.0 units/kg/day, add prandial insulin rather than continuing to escalate basal insulin alone. 2, 4

Signs of Overbasalization

• Basal insulin dose >0.5 units/kg/day 2
• Bedtime-to-morning glucose differential ≥50 mg/dL 2
• Hypoglycemia episodes 2
• High glucose variability 2
• Fasting glucose controlled but A1C remains elevated after 3-6 months 2, 3

Adding Prandial Insulin

• Start with 4 units of rapid-acting insulin before the largest meal 2, 4
• Alternative: Use 10% of current basal dose as initial prandial dose 2, 4
• Increase prandial insulin by 1-2 units or 10-15% every 3 days based on postprandial glucose 2, 4

Monitoring Requirements

During Active Titration

• Daily fasting blood glucose monitoring is essential 2, 4
• Check pre-meal glucose before each meal 4
• Check 2-hour postprandial glucose after largest meal when adding prandial insulin 4
• Reassess every 3-4 days during active dose adjustments 1, 4
• Reassess every 3-6 months once stable 4

Administration Guidelines

Critical Safety Points

• DO NOT dilute or mix Tresiba with any other insulin or solution 1
• DO NOT transfer from FlexTouch pen into syringe 1
• DO NOT administer intravenously or via insulin pump 1
• Inject subcutaneously into thigh, upper arm, or abdomen 1
• Rotate injection sites within same region to prevent lipodystrophy 1

Formulation-Specific Details

• U-100 formulation: Available as FlexTouch pen (delivers 1-80 units) and vial 1
• U-200 formulation: FlexTouch pen only (delivers 2-160 units in 2-unit increments) 1
• No dose conversion needed when using FlexTouch pens—dose window shows actual units to deliver 1
• For pediatric patients requiring <5 units daily, use U-100 vial 1

Special Populations and Situations

Hospitalized Patients

• For insulin-naïve or low-dose patients: 0.3-0.5 units/kg/day total, with half as basal 2
• For patients on high-dose home insulin (≥0.6 units/kg/day): reduce total daily dose by 20% to prevent hypoglycemia 2
• Lower doses (0.1-0.25 units/kg/day) for high-risk patients: elderly (>65 years), renal failure, poor oral intake 2

Missed Doses

• Adults: Inject during waking hours upon discovery, ensuring at least 8 hours between injections 1
• Pediatric patients: Contact healthcare provider for guidance and increase glucose monitoring until next scheduled dose 1

Concurrent Medications

• When adding SGLT2 inhibitors: Reduce total daily insulin by approximately 20% to prevent euglycemic ketoacidosis 5
• When adding GLP-1 receptor agonists: Consider as alternative to prandial insulin intensification 2, 4
• If on sulfonylureas: Reduce dose by 50% or discontinue when intensifying insulin 5

Common Pitfalls to Avoid

• Delaying insulin intensification when oral agents fail to achieve targets leads to prolonged hyperglycemia 2
• Continuing to escalate basal insulin beyond 0.5-1.0 units/kg/day without addressing postprandial hyperglycemia causes overbasalization and increased hypoglycemia risk 2
• Not reducing insulin dose by 10-20% when hypoglycemia occurs 2, 4
• Mixing or diluting Tresiba with other insulins (contraindicated due to unique formulation) 1
• Using U-200 formulation in patients requiring <10 units (use U-100 instead) 1
• Not ensuring adequate time between injections when using flexible dosing in adults (minimum 8 hours required) 1