What is the recommended protocol for transferring a patient from glargine (insulin glargine) insulin to Tresiba (insulin degludec)?

Transferring from Glargine to Tresiba (Insulin Degludec)

Transfer patients from glargine to Tresiba on a unit-to-unit basis, administering the first dose of Tresiba at the same time the next glargine dose would have been given, with no dose adjustment needed for most patients. 1, 2

Standard Transfer Protocol

For Patients on Once-Daily Glargine

• Administer Tresiba at the exact same total daily dose as the current glargine dose (unit-to-unit conversion) at the time when the next glargine injection would have been scheduled 1, 2
• Continue all prandial insulin doses unchanged during the transition 1, 2
• No bridging dose is necessary for once-daily glargine users 3

For Patients on Twice-Daily Glargine

• Calculate the total daily glargine dose (morning dose + evening dose) and administer this as a single daily dose of Tresiba 1
• Consider a 50% bridging dose of the evening glargine (50% of the evening glargine dose, NOT 50% of total daily dose) administered simultaneously with the first Tresiba dose to prevent hyperglycemia in the first 48 hours 3
• This bridging approach improved time-in-range by 8% in well-controlled twice-daily glargine users compared to a 9.5% decrease without bridging (p=0.027) 3
• The bridging dose is particularly beneficial for patients with HbA1c <75 mmol/mol (approximately <9%) who are well-controlled on twice-daily glargine 3

Timing and Administration Considerations

• Tresiba can be administered at any consistent time of day, providing flexibility that glargine does not offer, though establishing a consistent time initially is recommended 4, 5
• The ultra-long duration of action (>42 hours) means Tresiba provides more stable coverage than glargine's 24-hour profile 4, 5, 6
• Do not mix Tresiba with any other insulin in the same syringe, just as with glargine 7, 1

Monitoring Requirements During Transition

• Monitor fasting blood glucose daily for the first 2 weeks after transition to assess adequacy of basal coverage 1, 2
• Check for nocturnal hypoglycemia specifically, as Tresiba has demonstrated lower rates of nocturnal hypoglycemia compared to glargine in clinical trials 4, 6
• If hypoglycemia occurs, reduce Tresiba dose by 10-20% immediately 1, 2
• Reassess glycemic control at 3 months with HbA1c measurement 1, 2

Dose Titration After Transfer

• Wait at least 3-5 days before making dose adjustments to allow Tresiba to reach steady state, given its 17-21 hour half-life (roughly double that of glargine) 5
• Titrate based on fasting glucose values using standard algorithms: increase by 2 units every 3 days if fasting glucose 140-179 mg/dL, or by 4 units every 3 days if ≥180 mg/dL 1, 2
• Target fasting plasma glucose of 80-130 mg/dL 1, 2

Critical Pitfalls to Avoid

• Do not reduce the initial Tresiba dose "prophylactically" based on concerns about hypoglycemia—the unit-to-unit conversion is evidence-based and appropriate 1, 2, 3
• Do not delay the transition in patients experiencing frequent nocturnal hypoglycemia on glargine, as this is a specific indication where Tresiba shows superiority 4, 6
• Avoid using the 200 units/mL formulation unless the patient requires very high insulin doses, as this concentration creates confusion and overdose risk compared to standard 100 units/mL formulations 8
• Do not continue escalating basal insulin beyond 0.5 units/kg/day without adding prandial coverage, regardless of whether using glargine or Tresiba 1, 2

Special Populations

• For patients requiring high basal insulin doses (>80 units/day), the 200 units/mL Tresiba formulation reduces injection volume but requires careful patient education about the concentration difference 8, 4
• Elderly patients or those with renal impairment should start with conservative dosing (0.1-0.15 units/kg/day) if initiating insulin, but for transitions from glargine, maintain unit-to-unit conversion with closer monitoring 1, 2

Expected Clinical Benefits

• Reduced nocturnal hypoglycemia compared to glargine, particularly in type 1 diabetes (10-12% incidence with both insulins, but fewer severe episodes with Tresiba) 8, 4, 6
• More predictable day-to-day glucose-lowering effect due to lower within-patient variability compared to glargine 4, 5
• Flexibility in injection timing after stabilization, with the ability to vary injection times by 8-40 hours between doses without compromising control 8, 4