What is the recommended approach for converting a patient's basal insulin dose to Ryzodeg (insulin degludec/insulin aspart)?

Ryzodeg Dose Conversion

When converting to Ryzodeg (insulin degludec/insulin aspart), start with a unit-for-unit conversion from the patient's current basal insulin dose, administered once or twice daily with the largest meal(s), then titrate by 2 units once weekly based on fasting glucose targets. 1, 2

Initial Conversion Strategy

From Basal Insulin Only

• Convert unit-for-unit from the current basal insulin dose (glargine, detemir, degludec, or NPH) to Ryzodeg 1
• Administer Ryzodeg with the most carbohydrate-rich meal of the day 2
• For patients in very tight glycemic control or at high risk for hypoglycemia, reduce the initial dose by 10-20% 1
• Special consideration: When switching from insulin detemir or U-300 glargine, a 10-20% dose reduction is typically needed 1

From Premixed Insulin Regimens

• Calculate the total daily insulin dose from the premixed regimen 2
• Convert unit-for-unit to Ryzodeg, starting once daily with the largest meal 2
• If the patient was on premixed insulin twice daily, consider starting Ryzodeg twice daily with the two largest meals 2

From Basal-Bolus Regimens

• Add the total basal insulin dose plus the prandial insulin dose from the largest meal 2
• This combined dose becomes the starting Ryzodeg dose, administered with that meal 2
• Discontinue the prandial insulin at that meal but continue basal insulin from other meals initially 2

Titration Protocol

Weekly Dose Adjustments

• Increase by 2 units once weekly based on fasting plasma glucose readings 2
• Target fasting glucose: 80-130 mg/dL 1, 3
• If fasting glucose ≥180 mg/dL, consider increasing by 4 units 3
• If fasting glucose 140-179 mg/dL, increase by 2 units 3

Hypoglycemia Management

• If hypoglycemia occurs, reduce the dose by 10-20% immediately 1, 4
• If more than 2 fasting glucose values per week are <80 mg/dL, decrease by 2 units 3

Intensification to Twice-Daily Dosing

When to Intensify

• If HbA1c remains above target after 3-6 months on once-daily Ryzodeg 2
• When postprandial glucose excursions persist at meals not covered by the current dose 2
• When the once-daily dose exceeds 0.5 units/kg/day without achieving targets 1, 3

How to Split the Dose

• Divide the total daily dose between the two largest meals 2
• Start with approximately 50-60% of the total dose at the largest meal and 40-50% at the second meal 2
• Titrate each dose independently based on pre-meal glucose readings 2

Critical Thresholds and Warnings

Avoiding Overbasalization

• Stop escalating Ryzodeg when the dose exceeds 0.5-1.0 units/kg/day without achieving glycemic targets 1, 3
• Clinical signals of overbasalization include: bedtime-to-morning glucose differential ≥50 mg/dL, hypoglycemia, and high glucose variability 1, 3
• At this threshold, add separate rapid-acting insulin at other meals rather than continuing to increase Ryzodeg 1

Concomitant Medication Adjustments

• Continue metformin unless contraindicated 1, 5
• Sulfonylureas frequently need to be discontinued or dose-reduced when starting Ryzodeg 2
• When adding SGLT-2 inhibitors or GLP-1 receptor agonists, the Ryzodeg dose may need to be decreased by 10-20% 2

Special Populations

High-Risk Patients

• For elderly patients (>65 years), those with renal failure, or poor oral intake, start at the lower end of dosing (0.1 units/kg/day) 3, 4
• For hospitalized patients on high-dose home insulin (≥0.6 units/kg/day), reduce the total daily dose by 20% 3

Severe Hyperglycemia

• For patients with HbA1c ≥10-12% or blood glucose ≥300-350 mg/dL, consider starting Ryzodeg twice daily immediately with higher initial doses (0.3-0.5 units/kg/day total) 3, 5

Monitoring Requirements

• Daily fasting glucose monitoring during the titration phase 3, 5
• Check HbA1c every 3 months until target is achieved 5
• Assess for signs of overbasalization at every visit 1, 3