What is the recommended protocol for titrating Tresiba (insulin degludec)?

Titrating Tresiba (Insulin Degludec)

Initial Dosing

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

• For patients with more severe hyperglycemia (A1C ≥9% or blood glucose ≥300-350 mg/dL), consider higher starting doses of 0.3-0.4 units/kg/day. 1
• Continue metformin unless contraindicated when initiating basal insulin, as it reduces total insulin requirements and provides complementary glucose-lowering effects. 1

Standard Titration Algorithm

Increase Tresiba by 2-4 units every 3 days based on fasting plasma glucose values until reaching target of 80-130 mg/dL (4.4-7.2 mmol/L). 1

Specific Titration Schedule:

• If fasting glucose ≥180 mg/dL: Increase by 4 units every 3 days 1
• If fasting glucose 140-179 mg/dL: Increase by 2 units every 3 days 1
• If fasting glucose <80 mg/dL on more than 2 occasions per week: Decrease by 2 units 1

Critical Threshold: When to Stop Escalating Basal Insulin

When Tresiba exceeds 0.5 units/kg/day and approaches 1.0 units/kg/day, add prandial insulin rather than continuing to escalate basal insulin alone. 1

This threshold prevents "overbasalization," which leads to:

• Increased hypoglycemia risk 1
• High glucose variability 1
• Bedtime-to-morning glucose differential ≥50 mg/dL 1
• Suboptimal A1C control despite high basal doses 1

Adding Prandial Insulin

If after 3-6 months of basal insulin optimization, fasting glucose reaches target but A1C remains above goal, add prandial insulin. 1

• Start with 4 units of rapid-acting insulin before the largest meal or 10% of current basal dose 1
• Titrate prandial insulin by 1-2 units or 10-15% every 3 days based on postprandial glucose readings 1
• Add additional prandial doses to other meals as needed when postprandial glucose remains >180 mg/dL 2

Monitoring Requirements

• Daily fasting blood glucose monitoring is essential during titration 1
• Check A1C every 3 months until target is achieved 1
• Assess adequacy of insulin dose at every clinical visit, looking for signs of overbasalization 1

Hypoglycemia Management

• If hypoglycemia occurs without clear cause, immediately reduce the dose by 10-20% 1
• Patients should carry 15-20 grams of fast-acting carbohydrate at all times 1
• Prescribe glucagon for emergency use and educate family members on administration 1

Unique Properties of Tresiba

Tresiba has a duration of action >42 hours with a flat, stable glucose-lowering profile and less day-to-day variability than insulin glargine. 3 This ultra-long action allows for flexible dosing timing if needed, though consistency is preferred. 3

Common Pitfalls to Avoid

• Do not delay insulin intensification when oral agents fail to achieve glycemic targets 1
• Do not continue escalating basal insulin beyond 0.5-1.0 units/kg/day without addressing postprandial hyperglycemia—this leads to increased hypoglycemia risk and suboptimal control 1
• Do not abruptly discontinue oral medications when starting insulin therapy due to risk of rebound hyperglycemia 4
• Do not skip the 3-day titration interval in stable patients, as this unnecessarily prolongs time to achieve glycemic targets 1