What is the recommended initial dose of Tresiba (insulin degludec) when adding it to a patient's diabetic regimen?

Starting Dose of Tresiba (Insulin Degludec)

Yes, 10 units once daily is the recommended starting dose for insulin-naive patients with type 2 diabetes when adding Tresiba to their regimen. 1

FDA-Approved Starting Dose

The FDA label for insulin degludec explicitly states: "The recommended starting dose of Insulin Degludec in insulin naïve patients with type 2 diabetes mellitus is 10 units once daily." 1

This recommendation is consistently supported across multiple guideline societies including the American College of Physicians and American Diabetes Association, which endorse starting insulin-naive type 2 diabetes patients on 10 units or 0.1-0.2 units/kg body weight once daily. 2

Dosing Algorithm

Standard initiation approach:

• Start with 10 units once daily at the same time each day 3, 2, 1
• Continue metformin unless contraindicated 3
• Consider reducing sulfonylurea dose by 50% if the patient is on one, to minimize hypoglycemia risk 4

Titration schedule:

• Increase by 2 units every 3-4 days if fasting glucose is 140-179 mg/dL 3, 2, 1
• Increase by 4 units every 3-4 days if fasting glucose is ≥180 mg/dL 3, 2
• Target fasting plasma glucose of 80-130 mg/dL 3
• If hypoglycemia occurs, reduce dose by 10-20% 3, 2

When to Consider Higher Starting Doses

For patients with severe hyperglycemia (HbA1c ≥9%, blood glucose ≥300-350 mg/dL, or symptomatic/catabolic features), consider starting with 0.3-0.4 units/kg/day rather than the standard 10 units. 3, 2 These patients may require immediate basal-bolus insulin therapy rather than basal insulin alone. 3

Critical Threshold to Recognize

Stop escalating basal insulin when the dose exceeds 0.5 units/kg/day. 3, 2 At this point, add prandial insulin (starting with 4 units before the largest meal or 10% of basal dose) rather than continuing to increase Tresiba, as further escalation leads to "overbasalization" with increased hypoglycemia risk and suboptimal control. 3

Monitoring Requirements

• Daily fasting blood glucose monitoring is essential during titration 2
• Reassess every 3 days during active titration 2
• Check HbA1c every 3 months to assess overall glycemic control 4

Common Pitfalls to Avoid

• Do not delay titration - adjust every 3-4 days as recommended, not weekly or monthly 3, 1
• Do not discontinue metformin when adding insulin unless contraindicated 3
• Do not continue escalating basal insulin beyond 0.5-1.0 units/kg/day without addressing postprandial hyperglycemia with prandial insulin 3, 2
• Do not mix or dilute Tresiba with any other insulin or solution 1