What New Weekly Insulin Means for Type 2 Diabetes

In March 2026, the U.S. Food and Drug Administration approved insulin icodec-abae, the first-ever weekly basal insulin, as an alternative to daily insulin for individuals with Type 2 diabetes. The approval followed trials that studied 2,700 adults with Type 2 diabetes who were also taking mealtime insulin or an oral antidiabetic agent, a glucagon-like peptide-1 receptor agonist or both. Safety and efficacy of insulin icodec-abae was comparable to daily basal insulin.

Marketed by manufacturer Novo Nordisk as Awiqli®, the long-lasting insulin delivered weekly by injection pen became available in August.

In September, the FDA approved efsitora alpha, a weekly insulin pen sold as Onswik by Lilly. The company plans to make it available in the coming months.

To better understand what weekly insulin means for clinicians caring for patients with diabetes, Consult QD interviewed Diana Isaacs, PharmD, a Cleveland Clinic pharmacist who specializes in diabetes education.

How weekly insulin works

How does this drug fit into diabetes therapy?

Basal insulin is not a first-line Type 2 diabetes drug, but people who have been living with Type 2 diabetes for a long time may eventually need it to reach their glucose targets. If a person is already taking three or more non-insulin drugs or can’t tolerate other drugs and is not meeting their blood sugar goals, we start looking at adding a long-acting insulin. And now we really have a choice. We have had daily insulins, and now we have the first weekly.

What mechanisms allow these drugs to be given only once a week?

Insulin icodec binds reversibly to albumin, and that's what results in a depot in the circulation where the insulin icodec is slowly released over a week.

Efsitora alpha binds to a fusion protein allowing for slow release in the body allowing it to also be dosed just once a week.

One problem with daily insulin is if you miss your dose for some reason, now it's out of your system and your glucose levels are likely going to get really high. With this, hopefully you’ll be less likely to miss a dose. But even if you do, there's still going to be insulin working in the system, so it's unlikely someone's going to have dramatic high glucose levels unless they miss their usual dose by several days.

Best candidates

Who are the best potential candidates for weekly insulin?

This could be a great place to start for someone new to taking insulin, especially if they are already used to taking a GLP-1 drug. They may already be used to taking weekly shots, so it’s a really nice option and both could be taken at the same time each week.

This may also be good for people who have been on daily insulin but have struggled with missing doses. The switch to weekly insulin actually should make it easier to manage their blood sugar.

Another use case will, I think, be a big one: people who need help from caregivers. So maybe it's an older adult who has trouble using the pen, giving themselves insulin. Now they can have someone just come once a week and give it to them.

I also think this will be good for people that don’t like or are fearful of injections as this decreases weekly injections from seven to one per week.

Who might not be the best candidate for weekly insulin?

Someone who has really changing insulin needs. With weekly insulin it takes longer to get to a steady state and it's going to hang out in the system for longer. If something changes suddenly — maybe their eating habits dramatically change or they're being hospitalized — that might be someone with a little more risk of hypoglycemia on a weekly regimen.

Making the transition

What do clinicians need to know about transitioning patients from daily to weekly insulin?

One important consideration is that icodec-abae is actually a concentrated form of insulin. It is U700 insulin, basically seven times as concentrated as the insulin we're most familiar with, and it’s only available in a pen.

The advantage of being concentrated is that it reduces the volume a person will be injecting. But it’s going to look a lot higher than what people are used to because they are getting seven days’ worth at one time.

If a patient is just starting on this for the first time, it is recommended that you multiply their regular daily dose by seven to get what they will need in a week, but their first dose should be one and a half times their regular daily dose. You’re adding 50% more to get a loading dose. After that, they can resume the usual dose.

Also, the pen goes in 10-unit increments, so dosing needs to be rounded to the nearest 10. And that's really important because when you're prescribing it. You can't prescribe 105, for example, because the pharmacy will see that as incorrect instructions.

Efsitora will be available at u500 or u1000 insulin.

Do patients need to be checking their blood sugar more or less often?

Every person on insulin should have a continuous glucose monitor. Absolutely. Especially with dose increases, but guidelines from the major associations recommend that anyone taking insulin should have access to CGM for safety reasons.

Are there any other considerations we should discuss?

Dose adjustments are going to occur less often because you figure you can't adjust the dose more than once a week. But usually you're going to wait more like two to four weeks before dose adjustments so you can see the effect.