On March 26th, the FDA approved Novo Nordisk’s Awiqli (insulin icodec), the first once-weekly basal insulin. It is specifically indicated for treating adults with type 2 diabetes and is not approved for use in type 1 diabetes. By reducing the frequency of basal injections from 365 to 52 per year, insulin icodec aims to address common barriers to insulin therapy, including injection burden and treatment non-adherence. It is supplied in a prefilled FlexTouch pen that delivers doses in 10-unit increments. The maximum single injection is 700 units; doses requiring more than 700 units must be split into two injections. The pen is expected to be available in pharmacies in the second half of 2026.

In a trial (N=984) comparing it to daily insulin glargine, the Awiqli group had a greater reduction in A1C over 52 weeks (-1.55% vs 1.35%, p=0.02). However, rates of combined clinically significant or severe hypoglycemia were higher in the Awiqli group (0.30 events per person-year of exposure vs 0.16 events), underscoring the importance of proper patient selection when prescribing Awiqli.

A question many providers probably have is how to dose Awiqli. Those instructions are provided below.

• Insulin-naïve patients: 70 units once weekly on the same day each week


• Patients currently on daily basal insulin therapy:
• Give the first Awiqli dose on the day after the last dose of daily basal insulin
• Week 1 dosage (switching from daily basal): One-time starting dose equals 1.5 times the total daily basal dose multiplied by 7, rounded to the nearest 10 units
• Week 2 dosage (switching from daily basal): Previous total daily basal dose multiplied by 7, rounded to the nearest 10 units
• Week 3 dosage and beyond: Titrate from the prior weekly dose based on metabolic needs, blood glucose monitoring, and glycemic goals
• Missed doses: If a dose is missed, administer it as soon as possible within 4 days, then resume weekly dosing one week from the day the missed dose was taken; if more than 4 days have passed, skip the missed dose and take the next dose on the scheduled day; increase glucose monitoring with missed doses

• Weekly Icodec versus Daily Glargine U100 in Type 2 Diabetes without Previous Insulin, NEJM (2023) [PubMed abstract]
• Insulin chart (Awiqli®)