What is the recommended use and dosage of Tresiba (insulin degludec) for diabetes mellitus type 1 and 2?

Tresiba (Insulin Degludec) Dosing and Use

Type 1 Diabetes Mellitus

For insulin-naïve patients with type 1 diabetes, start Tresiba at approximately one-third to one-half of the total daily insulin dose, with the remainder given as short-acting insulin divided among meals. 1

• Calculate initial total daily insulin as 0.2-0.4 units/kg body weight, then allocate one-third to one-half as Tresiba once daily 1
• Typical total daily insulin requirements range from 0.4-1.0 units/kg/day, with approximately 50% as basal insulin 2
• For metabolically stable patients, 0.5 units/kg/day is a standard starting point 2
• Tresiba MUST be used concomitantly with short-acting insulin in type 1 diabetes 1

Switching from Other Basal Insulins (Type 1)

• Adults: Start Tresiba at the same unit dose as the total daily long or intermediate-acting insulin 1
• Pediatric patients (≥1 year): Start at 80% of the total daily long or intermediate-acting insulin dose to minimize hypoglycemia risk 1

Type 2 Diabetes Mellitus

For insulin-naïve patients with type 2 diabetes, start Tresiba at 10 units once daily. 1

• Alternative weight-based dosing: 0.1-0.2 units/kg/day 2
• Continue metformin unless contraindicated 2
• May be used alone or with oral antidiabetic agents or GLP-1 receptor agonists 3

Switching from Other Basal Insulins (Type 2)

• Adults: Start Tresiba at the same unit dose as the total daily long or intermediate-acting insulin 1
• Pediatric patients (≥1 year): Start at 80% of the total daily long or intermediate-acting insulin dose 1

Dose Titration

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

• If fasting glucose ≥180 mg/dL: increase by 4 units every 3 days 2
• If fasting glucose 140-179 mg/dL: increase by 2 units every 3 days 2
• If hypoglycemia occurs: reduce dose by 10-20% immediately 2
• When basal insulin exceeds 0.5 units/kg/day, consider adding prandial insulin or GLP-1 receptor agonist rather than continuing to escalate Tresiba alone 2, 3

Administration Guidelines

Inject Tresiba subcutaneously once daily at any time of day in adults; pediatric patients must inject at the same time every day. 1

• Inject into thigh, upper arm, or abdomen 1
• Rotate injection sites within the same region to reduce lipodystrophy risk 1
• DO NOT dilute, mix with other insulins, or administer intravenously 1
• DO NOT transfer from FlexTouch pen into a syringe 1
• Available as U-100 (100 units/mL) and U-200 (200 units/mL) formulations 1
• No dose conversion needed when using FlexTouch pens—the dose window shows actual units to deliver 1

Unique Pharmacological Properties

Tresiba has an ultra-long duration of action exceeding 42 hours with a flat, peakless profile and half-life of approximately 25 hours—twice as long as insulin glargine. 4, 5, 6

• Reaches steady state after approximately 3 days of once-daily dosing 5
• Four times lower day-to-day variability compared to insulin glargine 5
• Flexible dosing possible in adults: if a dose is missed, inject during waking hours ensuring at least 8 hours between consecutive injections 1
• Pediatric patients who miss a dose should contact their healthcare provider for guidance 1

Clinical Efficacy and Safety

Tresiba achieves similar glycemic control to insulin glargine but with significantly lower rates of nocturnal hypoglycemia. 4, 7

• In real-world studies, switching to Tresiba reduced overall hypoglycemia by 20% in type 1 diabetes and 54% in type 2 diabetes 7
• Severe hypoglycemia reduced by 72% in type 1 diabetes 7
• Nocturnal hypoglycemia reduced by 39% in type 1 diabetes and 65% in type 2 diabetes 7

Critical Thresholds and Treatment Advancement

Stop escalating Tresiba when dose exceeds 0.5 units/kg/day and A1C remains above target—add prandial insulin starting with 4 units before the largest meal or 10% of basal dose. 2

• Clinical signals of overbasalization: basal dose >0.5 units/kg/day, bedtime-to-morning glucose differential ≥50 mg/dL, hypoglycemia, high glucose variability 2
• Alternative to prandial insulin: add GLP-1 receptor agonist for improved glycemic control with less weight gain and hypoglycemia risk 2

Special Populations

• Pediatric patients requiring <5 units daily: Use Tresiba U-100 vial 1
• High-risk patients (elderly >65 years, renal failure, poor oral intake): Consider lower starting doses of 0.1-0.25 units/kg/day 2
• Pregnancy: Clinical experience is very limited; avoid use during pregnancy 8
• Patients requiring large insulin volumes: U-200 formulation available, delivering up to 160 units per injection 1

Common Pitfalls to Avoid

• Never share FlexTouch pens, needles, or syringes between patients—risk of blood-borne pathogen transmission 1
• Do not inject into areas of lipodystrophy or localized cutaneous amyloidosis 1
• Avoid continuing to escalate basal insulin beyond 0.5-1.0 units/kg/day without addressing postprandial hyperglycemia 2
• Do not delay addition of prandial insulin when signs of overbasalization are present 2
• Increase blood glucose monitoring frequency during insulin regimen changes 1