Tresiba (Insulin Degludec) Initial Dosing and Treatment Plan
Starting Doses by Diabetes Type
For insulin-naïve patients with type 2 diabetes, start Tresiba at 10 units once daily. 1 This is the FDA-approved starting dose and represents the standard approach for most patients beginning basal insulin therapy.
For insulin-naïve patients with type 1 diabetes, calculate 0.2-0.4 units/kg/day as the total daily insulin dose, then give approximately one-third to one-half of this as Tresiba (basal insulin), with the remainder as rapid-acting insulin divided among meals. 1 For example, a 70 kg patient would need 14-28 units total daily, with roughly 5-14 units as Tresiba and the rest as mealtime insulin. Type 1 diabetes patients must use Tresiba with short-acting insulin—never as monotherapy. 1
Administration Timing
Adults can inject Tresiba once daily at any time of day, with flexibility to vary the timing between doses as long as at least 8 hours have elapsed between injections. 1 This unique flexibility distinguishes Tresiba from other basal insulins. However, pediatric patients must inject Tresiba at the same time every day. 1
Dose Titration Protocol
Increase the Tresiba dose by 2-4 units every 3-4 days until fasting blood glucose reaches 80-130 mg/dL. 1, 2 The FDA label specifies 3-4 days between adjustments, allowing the ultra-long-acting insulin to reach steady state. Daily fasting blood glucose monitoring is essential during titration. 2
If hypoglycemia occurs, reduce the dose by 10-20% immediately after determining the cause. 3, 2
Foundation Therapy Considerations
Continue metformin when initiating Tresiba unless contraindicated. 2 Metformin reduces insulin requirements, minimizes weight gain, and decreases hypoglycemia risk when combined with insulin therapy.
When to Add Prandial Insulin
Add rapid-acting insulin when Tresiba has been optimized (fasting glucose 80-130 mg/dL) but A1C remains above target after 3-6 months, or when the Tresiba dose approaches 0.5-1.0 units/kg/day without achieving glycemic goals. 2 Start with 4 units of rapid-acting insulin before the largest meal, or use 10% of the basal dose. 2
Continuing to escalate Tresiba beyond 0.5-1.0 units/kg/day without addressing postprandial hyperglycemia leads to "overbasalization"—excessive basal insulin that masks inadequate mealtime coverage, causing hypoglycemia between meals while postprandial glucose remains elevated. 2
Switching from Other Insulins
Adults switching from another long-acting or intermediate-acting insulin should start Tresiba at the same unit dose as their previous basal insulin. 1 However, pediatric patients (≥1 year old) should start at 80% of their previous basal insulin dose to minimize hypoglycemia risk. 1 Close monitoring with increased blood glucose checks is required during any insulin transition. 1
Special Formulation Considerations
For pediatric patients requiring less than 5 units daily, use the Tresiba U-100 vial rather than the pen. 1 The U-200 pen delivers doses in 2-unit increments (minimum 2 units), making precise dosing of very small amounts impossible.
Never dilute, mix, or transfer Tresiba from the pen into a syringe. 1 The insulin's unique formulation requires administration exactly as provided in the delivery device.
Injection Technique
Rotate injection sites within the same region (thigh, upper arm, or abdomen) to prevent lipodystrophy and localized cutaneous amyloidosis. 1 Repeated injections into areas of lipodystrophy cause erratic absorption and hyperglycemia, while suddenly switching to an unaffected area can precipitate hypoglycemia. 1
Missed Dose Management
Adults who miss a dose should inject during waking hours upon discovery, ensuring at least 8 hours have elapsed since the last injection. 1 Pediatric patients who miss a dose should contact their healthcare provider for guidance and monitor blood glucose more frequently until the next scheduled dose. 1
Perioperative and Acute Illness Management
Administer 60-80% of the usual Tresiba dose on the day of surgery to maintain basal coverage while reducing hypoglycemia risk. 3 Monitor blood glucose at least every 2-4 hours during fasting periods and dose with short-acting insulin as needed. 3
Consider holding or reducing Tresiba during acute illness with poor oral intake, particularly in elderly patients (>65 years), those with renal failure, or those at high hypoglycemia risk. 3 However, never completely discontinue basal insulin in type 1 diabetes patients, as this precipitates diabetic ketoacidosis. 3
Critical Pitfalls to Avoid
Do not delay insulin initiation in patients failing to achieve glycemic goals with oral medications. 2 Prolonged hyperglycemia exposure increases complication risk.
Do not administer Tresiba intravenously or via insulin pump. 1 It is formulated exclusively for subcutaneous injection.
Do not perform dose conversion between U-100 and U-200 pens. 1 The dose window displays the actual units to deliver—no calculation is needed.
Do not continue escalating Tresiba beyond 0.5-1.0 units/kg/day without adding prandial insulin. 2 This creates dangerous overbasalization with increased hypoglycemia and suboptimal glycemic control.