How to reduce the risk of nocturnal hypoglycemia while taking Tresiba (insulin degludec)?

How to Reduce Tresiba for Nocturnal Hypoglycemia

Reduce your Tresiba dose by 10-20% immediately if you are experiencing nocturnal hypoglycemia, and ensure at least 3 consecutive nights of monitoring before making further adjustments. 1

Immediate Dose Reduction Strategy

• Decrease your current Tresiba dose by 10-20% as the first-line intervention for recurrent nocturnal hypoglycemia 1
• Wait at least 3-4 days between subsequent dose adjustments to allow the full effect of Tresiba to stabilize, given its ultra-long duration of action (>42 hours) 2, 3
• Monitor fasting blood glucose for at least 3 consecutive nights before making additional basal rate changes 1

Critical Assessment Before Adjusting

Check for overbasalization, which is the most common cause of nocturnal hypoglycemia with basal insulin:

• Calculate your bedtime-to-morning glucose differential: if ≥50 mg/dL (≥2.8 mmol/L), you are overbasalized 1, 4
• Assess if your basal insulin represents >50-60% of your total daily insulin dose—this signals excessive basal coverage 1
• Look for high glucose variability and large preprandial-to-postprandial glucose swings, which indicate too much basal and insufficient mealtime insulin 4

If overbasalized: You need to reduce Tresiba AND increase your mealtime insulin coverage, not just reduce basal insulin alone 4

Monitoring Protocol During Dose Reduction

• Check blood glucose at 2-3 AM for several nights to confirm the timing and severity of nocturnal hypoglycemia 4
• If bedtime glucose is <6 mmol/L (108 mg/dL), you have an 80% risk of nocturnal hypoglycemia—this is a critical threshold 5
• Continuous glucose monitoring (CGM) with alarms is strongly recommended, as nocturnal hypoglycemia is underestimated 40-60% of the time with fingerstick monitoring alone 1

Timing Considerations Specific to Tresiba

• Adults can inject Tresiba at any time of day, but ensure at least 8 hours between consecutive injections if a dose is missed 2
• Pediatric patients must inject at the same time every day to minimize hypoglycemia risk 2
• Consider whether adjusting your injection time (rather than just dose) might help—Tresiba's flexible dosing allows this without compromising control 3

Additional Prevention Strategies

Behavioral modifications to implement immediately:

• Consume 15-20 grams of carbohydrates at bedtime to reduce overnight hypoglycemia risk 1
• If you consume alcohol, always take it with food, as alcohol significantly increases hypoglycemia risk 1
• Adjust mealtime insulin if physical activity occurs within 1-2 hours of meals, as this can contribute to delayed nocturnal hypoglycemia 1

Technology-based solutions if dose reduction alone is insufficient:

• Automated insulin delivery (AID) systems with predictive low-glucose suspension features can reduce nocturnal hypoglycemia by 31.8% without worsening glucose control 1
• Sensor-augmented pump therapy with threshold suspend can prevent hypoglycemia in 75% of nights when it would otherwise occur 1

Common Pitfalls to Avoid

• Do not wait for multiple episodes before adjusting—recurrent hypoglycemia leads to hypoglycemia unawareness and impaired counterregulatory responses 1
• Do not make adjustments based on isolated readings—adjust only after documenting patterns over at least 3 consecutive nights 1
• Do not assume morning hyperglycemia means you need more insulin—this may actually be rebound from nocturnal hypoglycemia (check 3 AM glucose to distinguish) 4
• Avoid "stacking" correction doses in the evening, as insulin-on-board from dinner corrections can contribute to nocturnal lows 1

Evidence Supporting Tresiba's Lower Nocturnal Hypoglycemia Risk

Tresiba (insulin degludec) has demonstrated superior nocturnal hypoglycemia profiles compared to other basal insulins:

• In high-risk patients, Tresiba reduced nocturnal CGM-recorded hypoglycemia by 36% for glucose ≤3.9 mmol/L and 53% for glucose ≤3.0 mmol/L compared to insulin glargine U100 6
• The SWITCH 2 trial showed a 42% reduction in nocturnal symptomatic hypoglycemia with Tresiba vs glargine U100 in type 2 diabetes patients 7
• These benefits are primarily due to Tresiba's flat, stable glucose-lowering profile with less day-to-day variability 3, 8

Despite these advantages, dose reduction remains necessary when nocturnal hypoglycemia occurs, as the issue is typically excessive dosing rather than insulin choice 1, 2