What is the recommended dosing for Tresiba (insulin degludec) in patients with type 1 or type 2 diabetes?

Tresiba (Insulin Degludec) Dosing Guidelines

Starting Dose in Insulin-Naïve Patients

For type 2 diabetes, start Tresiba at 10 units once daily; for type 1 diabetes, use approximately one-third to one-half of the total daily insulin dose as Tresiba, with the remainder as short-acting insulin divided among meals. 1

Type 2 Diabetes Initial Dosing

• The FDA-approved starting dose is 10 units once daily for insulin-naïve patients with type 2 diabetes 1
• This aligns with standard basal insulin initiation protocols of 0.1-0.2 units/kg/day 2
• Continue metformin unless contraindicated when starting Tresiba 2

Type 1 Diabetes Initial Dosing

• Calculate total daily insulin requirement as 0.2-0.4 units/kg body weight 1
• Give one-third to one-half of this total as Tresiba (basal insulin) 1
• Administer the remaining portion as short-acting insulin divided between meals 1
• For metabolically stable patients, a typical starting point is 0.5 units/kg/day total, with approximately 40-60% as basal insulin 2

Dose Titration Protocol

Increase Tresiba by 2-4 units every 3-4 days based on fasting glucose levels until reaching target of 80-130 mg/dL. 2, 1

Standard Titration Algorithm

• If fasting glucose is ≥180 mg/dL: increase by 4 units every 3 days 2
• If fasting glucose is 140-179 mg/dL: increase by 2 units every 3 days 2
• Target fasting plasma glucose: 80-130 mg/dL 2
• The FDA recommends waiting 3-4 days between dose adjustments 1

Hypoglycemia Management

• If hypoglycemia occurs without clear cause, reduce dose by 10-20% immediately 2
• Monitor fasting blood glucose daily during titration 2

Switching from Other Insulins to Tresiba

Adults can switch unit-for-unit from their current long-acting insulin; pediatric patients should start at 80% of their previous long-acting insulin dose. 1

Adults with Type 1 or Type 2 Diabetes

• Start Tresiba at the same unit dose as the total daily long or intermediate-acting insulin 1
• Monitor closely for hypoglycemia during the transition 1

Pediatric Patients (≥1 Year Old)

• Start Tresiba at 80% of the total daily long or intermediate-acting insulin dose to minimize hypoglycemia risk 1
• This dose reduction is critical in children due to higher sensitivity 1

Critical Threshold: When to Add Prandial Insulin

When Tresiba exceeds 0.5 units/kg/day and approaches 1.0 units/kg/day, add prandial insulin rather than continuing to escalate basal insulin alone. 2, 3

Signs of "Overbasalization"

• Basal insulin dose >0.5 units/kg/day 2, 3
• Bedtime-to-morning glucose differential ≥50 mg/dL 2
• Episodes of hypoglycemia 2, 3
• High glucose variability throughout the day 2, 3

Adding Prandial Coverage

• Start with 4 units of rapid-acting insulin before the largest meal, or use 10% of current basal dose 2
• Titrate prandial insulin by 1-2 units every 3 days based on postprandial glucose 2

Unique Features of Tresiba

Tresiba offers flexible once-daily dosing with the ability to vary injection time by at least 8 hours between doses in adults, while maintaining glycemic control. 1, 4

Flexible Dosing in Adults

• Adults can inject Tresiba at any time of day, varying the time between doses 1
• Minimum interval between doses: 8 hours 1
• If a dose is missed, inject during waking hours upon discovery, ensuring 8 hours have elapsed since the last dose 1
• This flexibility is supported by Tresiba's ultra-long duration of action >42 hours 4, 5

Pediatric Dosing Requirements

• Pediatric patients must inject Tresiba at the same time every day 1
• If a dose is missed, contact healthcare provider for guidance and monitor glucose more frequently 1

Available Formulations and Administration

Tresiba is available in U-100 (100 units/mL) and U-200 (200 units/mL) concentrations; no dose conversion is needed when using FlexTouch pens. 1

U-100 Formulation

• Available as FlexTouch pen (delivers 1-80 units per injection) and 10 mL vial 1
• Use U-100 vial for pediatric patients requiring <5 units per day 1

U-200 Formulation

• Available as FlexTouch pen only (delivers 2-160 units per injection in 2-unit increments) 1
• Appropriate for patients requiring large volumes of basal insulin 4, 6
• The dose window shows actual units to deliver—no conversion required 1

Critical Safety Warnings

Never administer Tresiba intravenously, never mix with other insulins, and never transfer from pen to syringe. 1

Administration Restrictions

• DO NOT administer intravenously or via insulin pump 1
• DO NOT dilute or mix with any other insulin or solution 1
• DO NOT transfer from FlexTouch pen into a syringe 1
• Never share pens, needles, or syringes between patients 1

Monitoring Requirements

• Assess efficacy and safety at least monthly for first 3 months, then at least quarterly 7
• Increase frequency of glucose monitoring during any regimen changes 1
• Daily fasting glucose monitoring is essential during titration 2

Special Populations

Renal Impairment

• Dose adjustments may be needed with declining kidney function 1
• For CKD Stage 5: reduce total daily insulin by 50% for type 2 diabetes and 35-40% for type 1 diabetes 2
• Monitor closely for hypoglycemia as insulin clearance decreases 2

Hepatic Impairment

• Lower doses may be required 1
• Titrate conservatively based on clinical response 2

High-Risk Patients

• Elderly (>65 years), those with renal failure, or poor oral intake may require starting doses of 0.1-0.25 units/kg/day 2

Common Pitfalls to Avoid

• Never delay insulin initiation in patients not achieving glycemic goals with oral medications 2
• Never discontinue metformin when starting Tresiba unless contraindicated 2, 3
• Never continue escalating basal insulin beyond 0.5-1.0 units/kg/day without adding prandial coverage—this causes overbasalization with increased hypoglycemia risk 2, 3
• Never use sliding scale insulin as monotherapy—always provide scheduled basal coverage 2