What is the recommended dose of Tresiba (insulin degludec)?

Tresiba (Insulin Degludec) Dosing Recommendations

Initial Dosing for Type 2 Diabetes

For insulin-naive patients with type 2 diabetes, start Tresiba at 10 units once daily or 0.1-0.2 units/kg body weight once daily, administered at the same time each day. 1

• The American College of Physicians and American Diabetes Association support this starting range for patients with mild-to-moderate hyperglycemia 2, 1
• Continue metformin unless contraindicated when initiating basal insulin therapy 2
• For patients with severe hyperglycemia (HbA1c ≥9%, blood glucose ≥300-350 mg/dL, or symptomatic/catabolic features), consider higher starting doses of 0.3-0.4 units/kg/day 2, 1

Dose Titration Algorithm

Increase Tresiba by 2-4 units every 3-4 days until fasting blood glucose reaches 80-130 mg/dL. 2, 1

• If fasting glucose is ≥180 mg/dL: increase by 4 units every 3 days 2
• If fasting glucose is 140-179 mg/dL: increase by 2 units every 3 days 2
• If hypoglycemia occurs without clear cause: reduce dose by 10-20% immediately 2, 1
• Daily fasting blood glucose monitoring is essential during titration 2, 1

Initial Dosing for Type 1 Diabetes

For type 1 diabetes, start with a total daily insulin dose of 0.5 units/kg/day, giving approximately 50% as Tresiba (basal) once daily and 50% as rapid-acting insulin (prandial) divided among meals. 2

• Total daily insulin requirements typically range from 0.4 to 1.0 units/kg/day for type 1 diabetes 2
• Metabolically stable patients typically require 0.5 units/kg/day 2
• Patients in the honeymoon phase or with residual beta-cell function may require lower doses of 0.2-0.6 units/kg/day 2

Critical Threshold: When to Add Prandial Insulin

When basal insulin 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, 1

• Start with 4 units of rapid-acting insulin before the largest meal or 10% of the current basal dose 2, 1
• Clinical signals of "overbasalization" include: basal dose >0.5 units/kg/day, bedtime-to-morning glucose differential ≥50 mg/dL, hypoglycemia, and high glucose variability 2
• If after 3-6 months of optimized basal insulin the HbA1c remains above goal, add prandial insulin 2, 1

Unique Properties of Tresiba

Tresiba has a flat, stable glucose-lowering profile with a duration of action exceeding 42 hours and less day-to-day variability than insulin glargine 3, 4. This ultra-long action allows for flexible dosing timing without compromising glycemic control 3. The half-life exceeds 25 hours, producing a near-constant steady-state effect 4.

Special Formulations

• A 200 U/mL formulation of Tresiba is available for patients requiring large volumes of basal insulin 3
• Insulin degludec/aspart (IDegAsp) co-formulation is available, combining basal coverage with rapid-acting insulin aspart 5, 6

Common Pitfalls to Avoid

• Do not delay insulin initiation in patients not achieving glycemic goals with oral medications 2
• Do not continue escalating basal insulin beyond 0.5-1.0 units/kg/day without addressing postprandial hyperglycemia, as this leads to suboptimal control and increased hypoglycemia risk 2
• Do not wait longer than 3 days between basal insulin adjustments in stable patients, as this unnecessarily prolongs time to achieve glycemic targets 2
• Always continue metformin when adding or intensifying insulin therapy unless contraindicated 2