What is the recommended basal‑bolus insulin regimen using Tresiba (insulin degludec) and Novolog (insulin aspart) for a diabetic patient, including starting doses, titration schedule, and administration instructions?

Basal-Bolus Insulin Regimen Using Tresiba (Insulin Degludec) and Novolog (Insulin Aspart)

For patients with diabetes requiring basal-bolus therapy, initiate Tresiba at 10 units once daily (or 0.1-0.2 units/kg/day) combined with Novolog 4 units before each of the three main meals, administered 0-15 minutes before eating. 1, 2

Starting Doses

Basal Insulin (Tresiba/Degludec)

• Standard initiation: Begin with 10 units once daily or 0.1-0.2 units/kg/day for insulin-naïve patients with type 2 diabetes 1, 3, 2
• Severe hyperglycemia (A1C ≥9% or glucose ≥300 mg/dL): Start with 0.3-0.5 units/kg/day as total daily dose, allocating 50% to basal insulin 1, 3, 4
• Type 1 diabetes: Begin with approximately 0.5 units/kg/day total insulin, with 40-50% as basal (Tresiba) 1, 3, 4
• Administration timing: Tresiba can be administered at any consistent time of day due to its ultra-long duration of action exceeding 42 hours 5, 6, 7

Prandial Insulin (Novolog/Aspart)

• Initial dose: Start with 4 units before each of the three largest meals 1, 3
• Alternative calculation: Use 10% of the current basal dose per meal 1, 3
• Timing: Administer 0-15 minutes before meals for optimal postprandial control 1, 4
• Type 1 diabetes: Allocate 50-60% of total daily insulin as prandial, divided among three meals 1, 4

Titration Schedule

Basal Insulin (Tresiba) Titration

• Fasting glucose 140-179 mg/dL: Increase by 2 units every 3 days 1, 3, 2
• Fasting glucose ≥180 mg/dL: Increase by 4 units every 3 days 1, 3, 2
• Target fasting glucose: 80-130 mg/dL 1, 3, 2
• Hypoglycemia response: Reduce dose by 10-20% immediately if unexplained hypoglycemia occurs 1, 3

Prandial Insulin (Novolog) Titration

• Adjustment frequency: Increase each meal dose by 1-2 units (or 10-15%) every 3 days based on 2-hour postprandial glucose 1, 3, 4
• Target postprandial glucose: <180 mg/dL 1, 3, 4
• Carbohydrate-based dosing: Calculate insulin-to-carbohydrate ratio as 450 ÷ total daily insulin dose 3

Critical Threshold: Preventing Overbasalization

When Tresiba dose approaches 0.5-1.0 units/kg/day without achieving glycemic targets, add or intensify prandial Novolog rather than continuing to escalate basal insulin alone. 1, 3, 2

Warning Signs of Overbasalization

• Basal dose >0.5 units/kg/day 1, 3
• Bedtime-to-morning glucose differential ≥50 mg/dL 1, 3
• Episodes of hypoglycemia 1, 3
• High glucose variability throughout the day 1, 3

Administration Instructions

Tresiba (Degludec) Administration

• Flexible dosing: Tresiba's ultra-long duration (>42 hours) allows flexible once-daily dosing at any time, even with day-to-day variation in injection timing 5, 6, 7
• Injection sites: Subcutaneous injection in abdomen, thigh, or deltoid with proper site rotation 3
• Do not mix: Tresiba should never be mixed with other insulins due to its unique formulation 1, 7

Novolog (Aspart) Administration

• Timing: Inject 0-15 minutes before meals, ideally immediately before eating 1, 4
• Never at bedtime: Do not administer rapid-acting insulin at bedtime as sole correction dose—this markedly increases nocturnal hypoglycemia risk 1, 3
• Injection sites: Rotate subcutaneous injection sites to prevent lipohypertrophy 3

Monitoring Requirements

• Daily fasting glucose during titration phase to guide Tresiba adjustments 1, 3, 2
• Pre-meal glucose before each meal to calculate correction doses 3
• 2-hour postprandial glucose to assess Novolog adequacy 1, 3
• Bedtime glucose to evaluate overall daily pattern 3
• A1C every 3 months during intensive titration 3

Combination Therapy Considerations

• Continue metformin at maximum tolerated dose (up to 2,000-2,550 mg/day) unless contraindicated—this reduces total insulin requirements by 20-30% 1, 3, 2
• Discontinue sulfonylureas when initiating basal-bolus insulin to prevent additive hypoglycemia risk 1, 3
• GLP-1 receptor agonists may be considered as alternative to prandial insulin when basal exceeds 0.5 units/kg/day 1, 3

Special Populations

High-Risk Patients (Elderly, Renal Impairment, Poor Oral Intake)

• Start with lower doses: 0.1-0.25 units/kg/day total insulin 3, 2, 4
• Monitor more frequently for hypoglycemia 3

Hospitalized Patients

• Total daily dose: 0.3-0.5 units/kg/day (50% basal, 50% prandial) for non-critically ill patients eating regular meals 3, 4
• High-dose home insulin (≥0.6 units/kg/day): Reduce by 20% upon admission 3, 2, 4

Hypoglycemia Management

• Treatment threshold: Glucose <70 mg/dL 1, 3
• Immediate treatment: 15 grams fast-acting carbohydrate, recheck in 15 minutes, repeat if needed 1, 3
• Dose adjustment: Reduce implicated insulin by 10-20% if hypoglycemia occurs without clear cause 1, 3

Common Pitfalls to Avoid

• Never delay insulin initiation in patients not achieving glycemic goals with oral medications—this prolongs hyperglycemia exposure 1, 3
• Never discontinue metformin when starting insulin unless contraindicated—this leads to higher insulin requirements 1, 3
• Never continue escalating Tresiba beyond 0.5-1.0 units/kg/day without adding Novolog—this causes overbasalization with increased hypoglycemia 1, 3, 2
• Never use sliding-scale insulin as monotherapy—major diabetes guidelines condemn this approach as ineffective 1, 3

Expected Clinical Outcomes

• 68% of patients achieve mean glucose <140 mg/dL with properly implemented basal-bolus therapy versus 38% with sliding-scale alone 3
• A1C reduction of 2-3% (or 3-4% in severe hyperglycemia) achievable over 3-6 months 3
• Lower nocturnal hypoglycemia rates with degludec compared to insulin glargine 5, 7, 8
• No increased overall hypoglycemia when basal-bolus regimens are correctly implemented versus inadequate approaches 3, 4