How to Use Insulin Degludec
Insulin degludec should be injected subcutaneously once daily at any time of day in adults, though pediatric patients must inject at the same time every day. 1
Starting Doses
Type 1 Diabetes (Insulin-Naïve)
- Start with one-third to one-half of the total daily insulin requirement as degludec 1
- Calculate total daily insulin as 0.2–0.4 units/kg body weight 1
- The remainder should be given as rapid-acting insulin divided among meals 1
- Degludec MUST be used with short-acting insulin in type 1 diabetes 1
Type 2 Diabetes (Insulin-Naïve)
- Start with 10 units once daily 1
- Continue metformin unless contraindicated 2
- Consider discontinuing sulfonylureas to reduce hypoglycemia risk 2
Switching from Other Insulins
Adults (Type 1 or Type 2)
- Start degludec at the same unit dose as the total daily long- or intermediate-acting insulin 1
Pediatric Patients (≥1 Year Old)
- Start degludec at 80% of the total daily long- or intermediate-acting insulin dose to minimize hypoglycemia risk 1
Dose Titration
Titration Schedule
- Adjust doses every 3–4 days based on fasting glucose 1
- For fasting glucose 140–179 mg/dL: increase by 2 units 2
- For fasting glucose ≥180 mg/dL: increase by 4 units 2
- Target fasting glucose: 80–130 mg/dL 2
- If hypoglycemia occurs without clear cause, reduce dose by 10–20% immediately 2
Critical Threshold
- When basal insulin exceeds 0.5 units/kg/day, consider adding prandial insulin or a GLP-1 receptor agonist rather than continuing to escalate degludec alone 2
- Signs of "overbasalization" include: basal dose >0.5 units/kg/day, bedtime-to-morning glucose differential ≥50 mg/dL, hypoglycemia, and high glucose variability 2
Administration Technique
Injection Sites
- Inject into subcutaneous tissue of the abdomen, thighs, buttocks, or upper arms 3
- The abdomen has the fastest absorption rate, followed by arms, thighs, and buttocks 3
- Rotate within one area systematically (e.g., rotating within the abdomen) rather than switching areas with each injection 3
- Inject at least 1 cm from previous injection sites 3
- Avoid areas of lipodystrophy (lumps or indentations in the skin) 3
Injection Procedure
- Allow insulin to reach room temperature (leave out of refrigerator 30–60 minutes before injecting) to reduce pain and lipodystrophy risk 3
- Clean skin with alcohol swab and allow to evaporate 3
- Inject at a 90-degree angle 3
- Do NOT inject through clothing 3
Dosing Devices
- Degludec U-100 FlexTouch pen: delivers 1-unit increments, up to 80 units per injection 1
- Degludec U-200 FlexTouch pen: delivers 2-unit increments, up to 160 units per injection 1
- DO NOT perform dose conversion—the dose window shows the actual units to deliver 1
Flexible Dosing (Adults Only)
Missed Dose Protocol
- If a dose is missed, inject during waking hours upon discovery 1
- Ensure at least 8 hours have elapsed between consecutive injections 1
- Degludec's ultra-long duration (>42 hours) allows day-to-day variation in timing while maintaining efficacy and low nocturnal hypoglycemia risk 4, 5
Pediatric Patients
- Must inject at the same time every day 1
- If a dose is missed, contact healthcare provider for guidance and monitor glucose more frequently 1
Storage
Unopened Insulin
- Store in refrigerator at 2–8°C (36–46°F) 3
- Do NOT freeze 3
- Check refrigerator temperature, as household refrigerators commonly fall outside this range 3
Opened Insulin
- Store at room temperature 15–30°C (59–86°F) away from direct sunlight 3
- Discard after the manufacturer's expiration date (often 28 days for opened vials/pens) 3
- Use cooler packs/insulated bags when traveling in hot or cold conditions 3
Before Each Injection
Monitoring Requirements
During Titration
- Check fasting blood glucose daily 2
- Adjust doses every 3–4 days based on patterns, not single readings 2
Long-Term
- Reassess every 3–6 months to check HbA1c and adjust therapy 2
- Consider adding prandial insulin if HbA1c remains above target after 3–6 months despite achieving fasting glucose goals 2
Hypoglycemia Management
Recognition and Treatment
- Treat any glucose <70 mg/dL immediately with 15 grams of fast-acting carbohydrate 2
- Recheck in 15 minutes and repeat if needed 2
- All insulin users should carry at least 15g carbohydrate 3
- Family members should be trained in glucagon administration 3
Prevention
- Degludec has significantly lower rates of nocturnal hypoglycemia compared to insulin glargine (42–58% reduction in clinical trials) 6, 7
- The ultra-long, peakless profile provides more stable glucose control with less variability 7
Special Populations
Renal Impairment
- CKD Stage 5 with type 2 diabetes: reduce total daily insulin by 50% 8
- CKD Stage 5 with type 1 diabetes: reduce total daily insulin by 35–40% 8
- Monitor more frequently for hypoglycemia as insulin clearance decreases 2
Elderly or High-Risk Patients
- Start with lower doses (0.1–0.25 units/kg/day) in patients >65 years, those with renal failure, or poor oral intake 2
Hospitalized Patients
- For patients on high-dose home insulin (≥0.6 units/kg/day), reduce total daily dose by 20% upon admission 2
Common Pitfalls to Avoid
- Never use sliding-scale insulin as monotherapy in type 1 diabetes—it can precipitate diabetic ketoacidosis 2
- Never delay insulin initiation in patients not achieving glycemic goals with oral medications 2
- Never discontinue metformin when starting insulin unless contraindicated 2
- Do NOT continue escalating basal insulin beyond 0.5–1.0 units/kg/day without addressing postprandial hyperglycemia 2
- Do NOT inject cold insulin—allow it to reach room temperature first 3
- Do NOT inject through clothing 3
- Do NOT reuse needles or share pens between patients 3