Do Not Hold Tresiba (Insulin Degludec) When Patient Is Not Eating
Basal insulin like Tresiba should be continued at a reduced dose—not held completely—in patients who are not eating. This is essential to prevent diabetic ketoacidosis in type 1 diabetes and to suppress hepatic glucose production in type 2 diabetes 1.
Why Basal Insulin Must Be Continued
The fundamental principle is that basal insulin addresses background glucose control independent of meals. During illness or periods of poor oral intake, insulin requirements may be altered, but complete discontinuation of basal insulin can lead to severe hyperglycemia and metabolic derangement 2, 1.
- For type 1 diabetes patients: Basal insulin is absolutely required even when not eating to prevent diabetic ketoacidosis 1
- For type 2 diabetes patients: Basal insulin continues to suppress hepatic glucose production between meals and control fasting glucose 1
- The American Diabetes Association explicitly states that during illness, it is important that insulin be continued even if the patient is unable to eat or is vomiting 2
Dose Reduction Strategy
Rather than holding Tresiba completely, reduce the dose based on the patient's risk profile:
For Hospitalized Patients Not Eating:
- Reduce total daily insulin to 0.1-0.15 units/kg/day given primarily as basal insulin 1
- For high-risk patients (elderly >65 years, renal failure, poor oral intake): use 0.1-0.25 units/kg/day 3, 1
- If patient was on high-dose home insulin (≥0.6 units/kg/day), reduce total daily dose by 20% upon hospitalization 3, 1
Monitoring Requirements:
- Check glucose every 4-6 hours for patients not eating (rather than pre-meal testing) 2, 1
- Use correction doses of rapid-acting insulin only for significant hyperglycemia, typically >180-250 mg/dL 1
- A simplified correction scale: 2 units for glucose >250 mg/dL and 4 units for glucose >350 mg/dL 1
Critical Pitfall to Avoid
Completely withholding basal insulin when a patient is not eating is a dangerous error that leads to worsening hyperglycemia and potential metabolic crisis 4. The common misconception is that "no food = no insulin," but basal insulin works independently of meals to control background glucose levels 2.
Hypoglycemia Prevention
- If hypoglycemia occurs, reduce the basal insulin dose by 10-20% immediately 1
- The risk of hypoglycemia increases significantly in patients with renal impairment, hepatic impairment, elderly patients, and those with unpredictable oral intake 1
- Monitor closely for hypoglycemia, especially during overnight hours 4
Special Considerations for Tresiba
Tresiba (insulin degludec) has an ultra-long duration of action exceeding 42 hours with a flat, stable glucose-lowering profile 5, 6. This extended action means that even with reduced oral intake, the insulin continues to provide essential basal coverage with lower risk of hypoglycemia compared to other basal insulins 7, 6.