What is the recommended usage and dosage of Tresiba (insulin degludec) for patients with diabetes mellitus?

Tresiba (Insulin Degludec) Dosing and Usage Guidelines

Initial Dosing for Type 2 Diabetes

For insulin-naïve patients with type 2 diabetes, start Tresiba at 10 units once daily, administered at any time of day (though pediatric patients require same-time dosing), and titrate by 2 units every 3-4 days until fasting glucose reaches 80-130 mg/dL. 1, 2

• The FDA-approved starting dose is 10 units once daily for insulin-naïve type 2 diabetes patients 2
• Continue metformin unless contraindicated when initiating Tresiba 1
• Adults can inject at any time of day, but pediatric patients must inject at the same time daily 2
• Increase by approximately 2 units every 3-4 days to reach fasting plasma glucose goals without hypoglycemia 1
• If hypoglycemia occurs, reduce the dose by 10-20% 1

Initial Dosing for Type 1 Diabetes

For insulin-naïve patients with type 1 diabetes, start Tresiba at one-third to one-half of the total daily insulin dose (calculated as 0.2-0.4 units/kg), with the remainder given as short-acting insulin divided among meals. 2

• The FDA recommends approximately one-third to one-half of total daily insulin as Tresiba 2
• Total daily insulin requirements typically range from 0.2-0.4 units/kg for initial dosing 2
• Tresiba must be used concomitantly with short-acting insulin in type 1 diabetes 2
• The remainder of insulin should be administered as rapid-acting insulin at mealtimes 2

Switching from Other Insulins

When switching adults from other long-acting insulins to Tresiba, start at the same unit dose; for pediatric patients, start at 80% of the previous long-acting insulin dose to minimize hypoglycemia risk. 2

• Adults with type 1 or type 2 diabetes: use the same unit dose as the previous long or intermediate-acting insulin 2
• Pediatric patients (≥1 year): use 80% of the total daily long or intermediate-acting insulin dose 2
• Close medical supervision with increased blood glucose monitoring is required during the transition 2

Formulation and Administration Details

Tresiba is available in U-100 (100 units/mL) and U-200 (200 units/mL) concentrations; no dose conversion is needed when using FlexTouch pens as the dose window displays the actual units to be delivered. 2

• U-100 is available as FlexTouch pen (delivers 1-80 units) and 10 mL vial 2
• U-200 is available as FlexTouch pen only (delivers 2-160 units in 2-unit increments) 2
• For pediatric patients requiring <5 units daily, use the U-100 vial 2
• Never administer intravenously, in insulin pumps, or mix with other insulins 2
• Never transfer from pen to syringe for administration 2

Unique Flexibility Advantage

Tresiba's ultra-long duration of action (>42 hours) allows adults to inject at varying times of day, provided at least 8 hours elapse between consecutive injections, though pediatric patients must maintain consistent timing. 2, 3

• Adults who miss a dose should inject during waking hours upon discovery, ensuring ≥8 hours between doses 2
• Pediatric patients who miss a dose should contact their healthcare provider for guidance 2
• Clinical trials demonstrate flexible dosing (8-40 hour intervals) maintains glycemic control without compromising safety 3, 4
• This flexibility distinguishes Tresiba from other basal insulins that require fixed daily timing 4

Hypoglycemia Advantage

Tresiba demonstrates lower rates of nocturnal hypoglycemia compared to insulin glargine while achieving similar glycemic control, making it particularly valuable for patients with hypoglycemia concerns. 3, 4

• Clinical trials show similar HbA1c control to insulin glargine but with reduced nocturnal hypoglycemia risk 3
• The flat, stable glucose-lowering profile with less day-to-day variability contributes to this safety advantage 3
• Nocturnal hypoglycemia occurred significantly less frequently with Tresiba versus glargine in phase 3 trials 4

When to Add Prandial Insulin

When basal insulin optimization achieves fasting glucose targets but HbA1c remains above goal after 3-6 months, add prandial insulin rather than continuing to escalate Tresiba alone. 1

• Consider adding prandial insulin or GLP-1 receptor agonist when basal insulin is optimized but A1C remains elevated 1
• Start with rapid-acting insulin before the largest meal 1
• Combination with GLP-1 receptor agonist provides weight loss benefits and reduced hypoglycemia risk 1

Critical Monitoring Requirements

Self-monitoring of fasting blood glucose is essential during titration, with dose adjustments needed for changes in physical activity, meal patterns, renal/hepatic function, or acute illness. 1, 2

• Daily fasting glucose monitoring guides titration decisions 1
• Adjust doses with changes in physical activity, meal patterns, or during illness 2
• Increased monitoring frequency is required when making any insulin regimen changes 2

Common Pitfalls to Avoid

• Never delay insulin intensification when oral agents fail to achieve glycemic targets 1
• Do not use sliding scale insulin alone in type 1 diabetes patients 1
• Avoid sharing pens, needles, or syringes between patients due to blood-borne pathogen transmission risk 2
• Do not use during episodes of hypoglycemia or in patients with hypersensitivity to insulin degludec 2