How long does my patients’ basal insulin last?
Over the course of my more than 30 years as a practicing clinician and primary care educator, I have seen a lot of adult patients with diabetes try to manage their disease and maintain A1C control. Adding basal insulin to my patient’s treatment plan can be an effective way to improve glycemic control.
When I am prescribing a basal insulin, one of the considerations is duration of action. I am encouraged that my choices include basal insulins that last over 24 hours. Patients can get busy or distracted and forget or delay taking their insulin dose. I know most patients with diabetes don’t intend to miss a dose on purpose. But we’re all human, and we make mistakes. That’s why it was nice to learn about a basal insulin with dosing recommendations that allow my adult patients to take their daily dose at any time of the day. If they delay or miss a dose, they should take it as soon as they remember and then return to their regular dosing schedule. They just need to make sure there are at least 8 hours between injections.
Stephen Brunton, MD
- 30+ years as a practicing physician
- Executive Vice President for Education for the Primary Care Education Consortium (PCEC)
- Serves in an editorial role for 8 peer-reviewed journals
- Former President of the California Academy of Family Physicians and the Association of Family Medicine Residency Directors
- Winner of the American Medical Writers Association’s John P. McGovern Award for Excellence in Communication
Key features of Tresiba®
42+ hour duration of action1,a
Once-daily Tresiba® can provide patients with a glucose-lowering effect of at least 42 hours.a
aAfter the last of 8 once-daily injections (0.4 units/kg).
Dosed once daily and, for adults, at any time of day1
Adult patients can take Tresiba® once daily, at any time of day.
Flat and stable profile1-3
A smooth and steady release provides continuous coverage for longer than 24 hours.
Adult patients who miss a dose of Tresiba® should inject their daily dose during waking hours upon discovering the missed dose, then continue with their regular dosing schedule. Ensure that at least 8 hours have elapsed between Tresiba® injections.1
“Of course, patients should do their best to stay on schedule, but it’s nice to know that my patients’ dose timing can change if necessary with Tresiba®.”
Stephen Brunton, MD
Once-daily Tresiba® was studied at alternating dosing intervals of 8 to 40 hours between doses in adult patients with diabetes.1
As you work with adults with diabetes, you may see patients like these
Do you see patients like Sharon?
Sharon juggles family and work commitments.
With 3 kids and a consulting job, it is sometimes hard for Sharon to stick to a steady routine. Every day is an adventure starring rehearsals, sports practices, client meetings, and deadlines. Sometimes when it’s her turn to drive the carpool, Sharon forgets to take her morning insulin. With Tresiba®, Sharon can take her dose as soon as she gets home, as long as there are at least 8 hours between doses, and then return to her regular dosing schedule the next day.
Have you come across patients similar to Miguel?
Miguel is almost always on the road.
Miguel travels nearly every week for his job as an auditor. He feels like he spends more time in hotel rooms than in his own home. For Miguel, it can be a struggle just to remember what time zone he is in. Remembering to take his insulin at the same time every day sometimes gets lost in the shuffle. With Tresiba®, Miguel can take his daily dose later from time to time when he misses his regular dose.
Adult patients who miss a dose of Tresiba® should inject their daily dose during waking hours upon discovering the missed dose, then continue with their regular dosing schedule. Ensure that at least 8 hours have elapsed between Tresiba® injections.1
Hypothetical patients. Individual results may vary.
AN ENDOCRINOLOGIST’S POINT OF VIEW
Dr Steven Edelman explores the efficacy and safety of Tresiba®
INSULIN PENS AND PRIMARY CARE
Dr Stephen Brunton’s take on prescribing Tresiba® FlexTouch®
Indications and Usage for Tresiba® (insulin degludec) injection 100 U/mL, 200 U/mL
Tresiba® (insulin degludec) injection is indicated to improve glycemic control in patients 1 year of age and older with diabetes mellitus.
Limitations of Use
Tresiba® is not recommended for treating diabetic ketoacidosis.
Important Safety Information
Contraindications
- Tresiba® is contraindicated during episodes of hypoglycemia and in patients with hypersensitivity to insulin degludec or any of the excipients in Tresiba®
Warnings and Precautions
- Never Share a Tresiba® FlexTouch® Pen, Needle, or Syringe Between Patients, even if the needle is changed. Patients using Tresiba® vials should never share needles or syringes with another person. Sharing poses a risk for transmission of blood-borne pathogens.
- Hyperglycemia or Hypoglycemia with Changes in Insulin Regimen: Changes in an insulin regimen (e.g., insulin strength, manufacturer, type, or injection site or method of administration) may affect glycemic control and predispose to hypoglycemia or hyperglycemia. Repeated insulin injections into areas of lipodystrophy or localized cutaneous amyloidosis have been reported to result in hyperglycemia; and a sudden change in the injection site (to an unaffected area) has been reported to result in hypoglycemia. Make any changes to a patient’s insulin regimen under close medical supervision with increased frequency of blood glucose monitoring. Advise patients who have repeatedly injected into areas of lipodystrophy or localized cutaneous amyloidosis to change the injection site to unaffected areas and closely monitor for hypoglycemia. Adjustments in concomitant anti-diabetic treatment may be needed.
- Hypoglycemia: Hypoglycemia is the most common adverse reaction of insulin, including Tresiba®. Severe hypoglycemia can cause seizures, may be life-threatening or cause death. Hypoglycemia can impair concentration ability and reaction time; this may place the patient and others at risk in situations where these abilities are important (e.g., driving or operating other machinery). Hypoglycemia can happen suddenly and symptoms may differ in each patient and change over time in the same patient. Symptomatic awareness of hypoglycemia may be less pronounced in patients with longstanding diabetes, in patients with diabetic neuropathy, using drugs that block the sympathetic nervous system (e.g., beta-blockers) or who experience recurrent hypoglycemia. The long-acting effect of Tresiba® may delay recovery from hypoglycemia compared to shorter-acting insulins.
Risk Factors for Hypoglycemia: The risk of hypoglycemia generally increases with intensity of glycemic control. The risk of hypoglycemia after an injection is related to the duration of action of the insulin and, in general, is highest when the glucose lowering effect of the insulin is maximal. As with all insulins, the glucose lowering effect time course of Tresiba® may vary among different patients or at different times in the same patients and depends on many conditions, including the area of injection as well as the injection site blood supply and temperature. Other factors which may increase the risk of hypoglycemia include changes in meal pattern, changes in level of physical activity, or changes to concomitant drugs. Patients with renal or hepatic impairment may be at higher risk of hypoglycemia. Patients and caregivers must be educated to recognize and manage hypoglycemia. In patients at higher risk for hypoglycemia and patients who have reduced symptomatic awareness of hypoglycemia, increased frequency of blood glucose monitoring is recommended. - Hypoglycemia Due to Medication Errors: Accidental mix-ups between insulin products have been reported. To avoid medication errors between Tresiba® and other insulins, always instruct patients to always check the insulin label before each injection. To avoid dosing errors and potential overdose, never use a syringe to remove Tresiba® from the Tresiba® FlexTouch® disposable insulin prefilled pen.
- Hypersensitivity Reactions: Severe, life-threatening, generalized allergy, including anaphylaxis, can occur with insulins, including Tresiba®. If hypersensitivity reactions occur, discontinue Tresiba®; treat per standard of care and monitor until symptoms and signs resolve.
- Hypokalemia: All insulins, including Tresiba®, cause a shift in potassium from the extracellular to intracellular space, possibly leading to hypokalemia. Untreated hypokalemia may cause respiratory paralysis, ventricular arrhythmia, and death. Monitor potassium levels in patients at risk for hypokalemia and treat if indicated.
- Fluid Retention and Heart Failure with Concomitant Use of PPAR-gamma Agonists: Fluid retention and heart failure can occur with concomitant use of thiazolidinediones (TZDs), which are PPAR-gamma agonists, and insulin, including Tresiba®. Patients should be observed for signs and symptoms of heart failure. If heart failure occurs, dosage reduction or discontinuation of the TZD must be considered.
Adverse Reactions
- Adverse reactions commonly associated with Tresiba® are hypoglycemia, allergic reactions, injection site reactions, lipodystrophy, pruritus, rash, edema, and weight gain.
Drug Interactions
- There are certain drugs that may cause clinically significant drug interactions with Tresiba®.
- Drugs that may increase the risk of hypoglycemia: antidiabetic agents, ACE inhibitors, angiotensin II receptor blocking agents, disopyramide, fibrates, fluoxetine, monoamine oxidase inhibitors, pentoxifylline, pramlintide, salicylates, somatostatin analog (e.g., octreotide), sulfonamide antibiotics, GLP-1 receptor agonists, DPP-4 inhibitors, and SGLT-2 inhibitors
- Drugs that may decrease the blood glucose lowering effect: atypical antipsychotics (e.g., olanzapine and clozapine), corticosteroids, danazol, diuretics, estrogens, glucagon, isoniazid, niacin, oral contraceptives, phenothiazines, progestogens (e.g., in oral contraceptives), protease inhibitors, somatropin, sympathomimetic agents (e.g., albuterol, epinephrine, terbutaline), and thyroid hormones
- Drugs that may increase or decrease the blood glucose lowering effect: alcohol, beta-blockers, clonidine, lithium salts, and pentamidine
- Drugs that may blunt the signs and symptoms of hypoglycemia: beta-blockers, clonidine, guanethidine, and reserpine
Please click here for Tresiba® Prescribing Information.
References:
- Tresiba [package insert]. Plainsboro, NJ: Novo Nordisk Inc; July 2022.
- Heise T, Korsatko S, Nosek L, et al. J Diabetes. 2016;8(1):132-138.
- Heise T, Hermanski L, Nosek L, Feldman A, Rasmussen S, Haahr H. Diabetes Obes Metab. 2012;14(9):859-864.