What is the recommended dosing strategy when switching from Lantus (insulin glargine) to Tresiba (insulin degludec)?

Switching from Lantus to Tresiba: Recommended Dosing Strategy

When switching from Lantus (insulin glargine) to Tresiba (insulin degludec), convert the total daily dose unit-for-unit (1:1 ratio) and administer once daily, but expect to increase the Tresiba dose by approximately 12% over the following weeks while reducing mealtime insulin by approximately 11% to maintain glycemic control. 1

Initial Conversion Algorithm

Standard-Risk Patients

• Calculate the total daily Lantus dose and convert it unit-for-unit to once-daily Tresiba 2
• Administer Tresiba at the same time each day, recognizing its ultra-long duration of action (>42 hours) 3
• Begin titration based on fasting glucose monitoring after the switch 2

High-Risk Patients

For patients at elevated risk of hypoglycemia (elderly, renal impairment, history of severe hypoglycemia):

• Reduce the converted dose by 10-20% from the total daily Lantus dose 2
• Monitor more frequently during the first 1-2 weeks 2

Post-Conversion Dose Adjustments

Expected Dose Changes

Real-world data from pediatric and adolescent patients demonstrates a consistent pattern:

• Increase Tresiba dose by approximately 12.5% over 12 months 1
• Decrease mealtime insulin dose by approximately 11.6% over the same period 1
• These adjustments maintain or improve glycemic control while reducing hypoglycemia risk 1

Titration Schedule

• Monitor fasting blood glucose daily during the first 1-2 weeks after conversion 2
• Adjust the dose every 3 days based on fasting glucose values, targeting 80-130 mg/dL 4, 2
• If fasting glucose is 140-179 mg/dL, increase by 2 units every 3 days 4
• If fasting glucose is ≥180 mg/dL, increase by 4 units every 3 days 4

Clinical Advantages of Tresiba Over Lantus

Hypoglycemia Reduction

• Tresiba reduces nocturnal hypoglycemia by 25% compared to Lantus in type 1 diabetes 3
• Nocturnal time below range (<3.9 mmol/L) is reduced by 0.88% (12.7 minutes/night) in type 2 diabetes 5
• Overall hypoglycemia rates are similar or lower with Tresiba 3, 5

Glycemic Control

• Tresiba provides 1.43% more time in range (3.9-10.0 mmol/L) compared to Lantus, equivalent to 20.6 additional minutes per day 5
• HbA1c reductions are non-inferior to Lantus, with some studies showing superior outcomes in poorly controlled patients 1, 3
• In patients with HbA1c >7.5%, switching to Tresiba reduced HbA1c from 8.46% to 7.89% at 3 months 1

Dosing Efficiency

• Tresiba requires approximately 27% less insulin per day compared to Lantus to achieve similar glycemic control 6
• Patients experience fewer hypoglycemic episodes while using lower total insulin doses 6

Critical Monitoring Points

First Two Weeks

• Daily fasting blood glucose monitoring is essential 2
• If hypoglycemia occurs, reduce the dose immediately by 10-20% 4, 2
• Assess for patterns of nocturnal hypoglycemia, which should decrease with Tresiba 3, 5

Weeks 2-12

• Continue fasting glucose monitoring at least 3-4 times weekly 4
• Expect gradual dose increases of Tresiba (up to 12% total) while reducing mealtime insulin 1
• Reassess adequacy at every clinical visit 4

Common Pitfalls to Avoid

Inadequate Dose Adjustment

• Do not maintain the exact 1:1 conversion indefinitely—most patients require a 12% increase in Tresiba dose over time 1
• Failing to reduce mealtime insulin appropriately can lead to hypoglycemia 1

Premature Dose Escalation

• Wait at least 3 days between dose adjustments to allow Tresiba to reach steady state 4
• Some experts recommend waiting up to 1 week for ultra-long-acting insulins before subsequent adjustments 4

Ignoring Mealtime Insulin Adjustments

• Proactively reduce mealtime insulin by approximately 11% as Tresiba dose is optimized 1
• Monitor postprandial glucose to guide mealtime insulin reductions 1

Overlooking Hypoglycemia Risk Reduction

• Patients previously experiencing frequent nocturnal hypoglycemia on Lantus should be counseled that this risk decreases with Tresiba 3, 5
• Adjust doses downward if hypoglycemia occurs rather than accepting it as inevitable 2

Special Populations

Type 1 Diabetes

• Maintain basal-bolus regimen with approximately 40-50% of total daily insulin as Tresiba 4
• Expect improved nocturnal glucose control with 25% fewer nocturnal hypoglycemic episodes 3

Type 2 Diabetes

• Continue metformin and other non-insulin agents unless contraindicated 4
• Tresiba provides superior time in range and reduced nocturnal hypoglycemia compared to Lantus 5
• Consider that 69% of patients may reach HbA1c ≤7% with Tresiba versus 41% with Lantus 6

Poorly Controlled Patients (HbA1c >7.5%)

• Expect significant HbA1c reductions (0.57% at 3 months) after switching from Lantus to Tresiba 1
• More aggressive titration may be appropriate in this population 1