How should insulin degludec (insulin degludec) be administered to an adult patient with type 2 diabetes and potentially impaired renal function?

How to Administer Insulin Degludec

Inject insulin degludec subcutaneously once daily at any time of day in adults, but pediatric patients must inject at the same time every day. 1

Administration Basics

Timing and Frequency

• Adults: Inject once daily at any time of day, with flexibility to vary timing between doses as long as at least 8 hours have elapsed between consecutive injections 1, 2
• Pediatric patients (≥1 year): Inject once daily at the same time every day 1
• The ultra-long action profile (>24 hours) allows for flexible dosing schedules in adults, which is particularly useful for patients with unpredictable work schedules or frequent travel 2, 3

Route and Technique

• Administer subcutaneously only 1
• Rotate injection sites to prevent lipodystrophy or localized cutaneous amyloidosis, as repeated injections into affected areas can cause hyperglycemia 1
• If switching from an affected area to an unaffected site, monitor closely for hypoglycemia 1

Available Formulations and Devices

Concentration Options

• U-100 (100 units/mL): Available as FlexTouch pen (3 mL) or multiple-dose vial (10 mL) 1
• U-200 (200 units/mL): Available as FlexTouch pen (3 mL) only 1

Dosing Increments

• U-100 FlexTouch pen: Delivers 1-unit increments, up to 80 units per injection 1
• U-200 FlexTouch pen: Delivers 2-unit increments, up to 160 units per injection 1
• No dose conversion is needed when using either pen—the dose window shows the actual units to be delivered 1

Starting Doses

Type 1 Diabetes (Insulin-Naïve)

• Start with one-third to one-half of the total daily insulin dose as insulin degludec 1
• Calculate initial total daily insulin dose as 0.2 to 0.4 units/kg 1
• The remainder must be given as short-acting insulin divided among meals, as insulin degludec alone is insufficient for type 1 diabetes 1

Type 2 Diabetes (Insulin-Naïve)

• Start with 10 units once daily 1
• This aligns with standard basal insulin initiation recommendations 4

Switching from Other Insulins

Adults with Type 1 or Type 2 Diabetes

• Start insulin degludec 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

Dose Titration

Titration Schedule

• Adjust doses every 3 to 4 days based on blood glucose monitoring 1
• This is consistent with standard basal insulin titration protocols 4

Situations Requiring Dose Adjustment

• Changes in physical activity 1
• Changes in meal patterns (macronutrient content or timing) 1
• Changes in renal or hepatic function 1
• During acute illness 1

Special Considerations for Renal Impairment

While the provided evidence doesn't specify exact dose adjustments for insulin degludec in renal impairment, general insulin principles apply:

• Monitor closely for hypoglycemia as insulin clearance decreases with declining kidney function 5
• Consider more conservative titration in patients with eGFR <45 mL/min/1.73 m² 5

Missed Dose Management

Adults

• Inject the missed dose during waking hours upon discovery 1
• Ensure at least 8 hours have elapsed between consecutive injections 1

Pediatric Patients

• Contact healthcare provider for guidance 1
• Monitor blood glucose levels more frequently until the next scheduled dose 1

Critical Safety Warnings

Never Share Devices

• Never share FlexTouch pens, needles, or syringes between patients, even if the needle is changed, due to risk of blood-borne pathogen transmission 1

Contraindications

• Do not use during episodes of hypoglycemia 1
• Contraindicated in patients with hypersensitivity to insulin degludec or any excipients 1

Hypoglycemia Risk

• Hypoglycemia is the most common adverse reaction 1
• Severe hypoglycemia can cause seizures, may be life-threatening, or cause death 1
• Symptoms may differ between patients and change over time in the same patient 1

Combination Therapy Considerations

Type 1 Diabetes

• Must be used concomitantly with short-acting insulin 1
• Degludec provides only basal coverage 1

Type 2 Diabetes

• Continue metformin unless contraindicated when initiating insulin degludec 4
• Consider GLP-1 receptor agonists as preferred add-on therapy before advancing to prandial insulin 4
• When basal insulin exceeds 0.5 units/kg/day without achieving glycemic targets, add prandial insulin rather than continuing to escalate basal insulin alone 4