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

Tresiba Maximum Dose

There is no absolute maximum dose of Tresiba (insulin degludec) specified in clinical guidelines or product labeling; however, when basal insulin exceeds 0.5 units/kg/day and approaches 1.0 units/kg/day, adding prandial insulin becomes more appropriate than continuing to escalate basal insulin alone. 1

Practical Dosing Thresholds

• The critical threshold for basal insulin is 0.5 units/kg/day, beyond which further escalation often leads to "overbasalization" rather than improved glycemic control 1

• Clinical signals that you've exceeded optimal basal insulin dosing include:

  • Basal insulin dose >0.5 units/kg/day 1
  • Bedtime-to-morning glucose differential ≥50 mg/dL 1
  • Hypoglycemia episodes 1
  • High glucose variability 1

• When basal insulin approaches 0.5-1.0 units/kg/day without achieving glycemic targets, the American Diabetes Association recommends adding prandial insulin (starting with 4 units before the largest meal or 10% of current basal dose) rather than continuing to increase Tresiba 1

Dosing Algorithm

Initial dosing:

• Start with 10 units once daily or 0.1-0.2 units/kg/day for insulin-naive type 2 diabetes patients 1
• For severe hyperglycemia (A1C ≥9%, glucose ≥300-350 mg/dL), consider 0.3-0.5 units/kg/day as total daily dose with basal-bolus therapy 1

Titration:

• Increase by 2 units every 3 days if fasting glucose 140-179 mg/dL 1
• Increase by 4 units every 3 days if fasting glucose ≥180 mg/dL 1
• Target fasting plasma glucose: 80-130 mg/dL 1

When to stop escalating Tresiba:

• Once dose exceeds 0.5 units/kg/day, add prandial insulin or GLP-1 receptor agonist instead of further basal increases 1
• Continuing to escalate basal insulin beyond this threshold leads to suboptimal control and increased hypoglycemia risk 1

Special Considerations for Tresiba

• Tresiba has an ultra-long duration of action (>42 hours) with less day-to-day variability than insulin glargine 2
• A 200 units/mL formulation is available for patients requiring large volumes of basal insulin, though this creates potential confusion and overdose risk 3, 2
• Tresiba can be administered at flexible times with varying intervals of 8-40 hours between doses without compromising glycemic control 3

Common Pitfalls to Avoid

• Do not continue escalating Tresiba indefinitely - recognize the 0.5 units/kg/day threshold as a signal to add adjunctive therapy 1
• Do not ignore postprandial hyperglycemia - blood glucose elevations despite adequate fasting control indicate need for prandial coverage, not more basal insulin 1
• Do not delay adding prandial insulin when signs of overbasalization appear, as this prolongs poor glycemic control and increases hypoglycemia risk 1