Overview

Patients with type 2 diabetes mellitus (T2DM) requiring insulin therapy currently have multiple options to choose from between bolus (short-acting) insulin, basal (long-acting) insulin, and premixed (long-acting and rapid/intermediate). Studies have reported the number of patients with T2DM using insulin have continued to increase with approximately 109,974 users in 2002 and reaching 348,254 users in 2019. No matter which type of insulin a patient is on, daily injections are still required.

When initiating insulin therapy in T2DM patients, the American Diabetes Association recommends starting patients on basal insulin alone before transitioning to a basal/bolus regimen. In order for insulin injections to be effective, patients must be adherent to their dosing schedule. A post-hoc analysis published in the Diabetes Research and Clinical Practice reported that the weekly averages of T2DM patients being adherent to their basal insulin regimen ranged from 70.6% to 79.3%. A recently approved once-weekly injection could not only promote adherence, but it could also reduce the burden of daily injections associated with basal insulin as well as providing patients with the potential for stable, long-lasting glucose control.

The Arrival of a New Era in Insulin Therapy

On March 26^th, 2026, the US Food and Drug Administration (FDA) approved Awiqli® (insulin icodec-abae), a novel once-weekly basal insulin for the treatment of type 2 diabetes. Awiqli® is to be injected every 7 days, on the same day each week, offering a more convenient dosing schedule compared to current once daily basal insulins. Trials from the ONWARD program demonstrated non-inferiority and, in some cases, superiority when compared to the standard insulin degludec and glargine. The primary outcome measured included a reduction in hemoglobin A1c. The insulin icodec group had a reduction of 8.6% to 7.0% meanwhile the insulin degludec group had a reduction of 8.5% to 7.2%.

The Science Behind Once-Weekly Control

Awiqli® mimics the natural insulin that the body produces and binds to human insulin receptors. The insulin is highly protein bound (>99%) resulting in a half-life of approximately 7 days which allows for the once-weekly dosing. Once bound, a depot is formed in the bloodstream which allows the insulin to be slowly released over time and results in gradual and consistent glucose control. Steady state is reached after a couple of weeks of injections and will further maintain a continuous, steady equilibrium.

Although this insulin has many promising factors, there are some instances where a clinician may want to proceed with caution in recommending this product for a patient. Due to the long half-life, this medication remains in the body for a longer period of time. If the medication is dosed too high, the patient could experience more frequent hypoglycemic episodes. The same can be said if a patient experiences an allergic reaction. It will take longer for the body to excrete this medication compared to the current basal insulin therapies.

The Art of Dosing Once-Weekly Insulin

Awiqli® is formulated into a pre-filled pen that contains 700 units/mL. The pen is designed to deliver doses rounded to the nearest 10-unit increment (e.g. 70 units, 80 units, 90 units, and so on).

The manufacturer, Novo-Nordisk, recommends starting patients on 70 units once weekly if the patient is basal insulin naïve, then titrating as necessary. Alternatively, if the patient is switching from a daily basal insulin to Awiqli®, the first week dose is calculated by multiplying the patient’s current daily basal dose by 1.5 then further multiplying this by 7 and rounding to the closest 10 units. For the second week, take the patient’s previous total daily dose of basal insulin, multiply this by 7, and round to the closest 10 units. After the second week, it is recommended to continue titrating as clinically indicated.

Practice Pearls for Pharmacists

Although a once-weekly injection sounds like the ideal insulin regimen, it may not be the best choice for all patients. With the recent FDA approval, it was only approved for patients with T2DM. Patients with type 1 diabetes mellitus (T1DM) were included in studies, but it was not approved in this patient population due to an increased risk of hypoglycemia. Furthermore, it was only studied in adults aged 18 and older, so therefore, it is not approved in children.

A patient that could be a good candidate for this novel basal insulin therapy may be one who struggles with adherence, varying glucose control, or someone just overwhelmed with daily injections. With the once-weekly dosing, pharmacists play a key role in educating patients on Awiqli®. Some important considerations include:

• Emphasizing a once-a-week injection rather than daily – the dose is much higher than standard daily dosing so an administration error of injecting the prescribed dose daily could result in extreme episodes of hypoglycemia.
• Educating on how to combat hypoglycemia – since this medication sticks around longer in the body, if the dose is too high (especially if the patient is taking other anti-glycemic medications), then hypoglycemic episodes could potentially last longer and/or occur more frequently.
• Monitoring daily blood glucose levels – when the patient is starting out on Awiqli®, the dose may need to be titrated, so having current and accurate blood glucose readings will help guide these dose changes.
• Missing doses – if a patient misses a dose, it is best to take the dose as soon as possible if it is within 4 days of the injection date. If it has been more than 4 days, it is best to wait until the next scheduled injection date.

The Patient Experience with Once-Weekly Insulin

As stated previously, patient adherence to prescribed anti-glycemic therapy is important in maintaining blood glucose control and preventing hyperglycemic episodes that could lead to a wide array of health complications. The novel once-weekly mechanism provides an option for patients who are struggling with adherence resulting in varying glucose control. It also has a role for patients who are just overwhelmed with the burden associated with managing their T2DM and daily basal insulin injections.

Patients can expect to see this medication being available in the coming months of 2026. The cost of Awiqli® is still not readily available. Due to this being a new medication and with recent FDA approval, it could be expected to be on the more expensive end. It will also be interesting to see what insurance coverage looks like in the coming months. Will insurances require a prior authorization? Will step therapy be required? Access to this medication will determine if patients will actually be able to benefit from it.

Is Weekly the Future of Diabetes Care?

While the number of patients with T2DM using insulin therapy continue to rise, we continue to see poor adherence leading to poor glucose control among this patient population. The newly FDA approved medication Awiqli® (insulin icodec-abae), could help target this specific patient population with providing the possibility of better adherence and decreased injection burden due to the medication’s once-weekly dosing. In addition, it could benefit patients who have varying glucose control with the mechanism of action of forming a depot in the bloodstream to provide a slow, constant, and steady release of insulin. This medication is not without its challenges. Dosing has to be just right because if it is too high, the patient could experience prolonged hypoglycemic episodes. Patient access to this medication in regard to cost and insurance coverage still remains a topic of discussion. What comes next is still up in the air. Practitioners could expect to see changes in diabetes guidelines in the future which could potentially impact the standards of care in patients with T2DM. This may be the end of a chapter for previous therapies, but this is a promising start of a new era in basal insulin therapy.

Olivia Johnson, PharmD

References:

1. Highlights of prescribing information. Accessed March 31, 2026. https://www.novo-pi.com/awiqli.pdf
2. Pharmacytimes.com. Published 2026. Accessed March 31, 2026. https://www.pharmacytimes.com/view/fda-approves-insulin-icodec-abae-first-once-weekly-basal-insulin-for-adults-with-t2d
3. Home: Awiqli. Awiqli.ca. Published 2026. https://awiqli.ca/en/
4. Ajmc.com. Published 2026. https://www.ajmc.com/view/fda-approves-novel-weekly-basal-insulin-for-t2d
5. Awiqli | European Medicines Agency. www.ema.europa.eu. https://www.ema.europa.eu/en/medicines/human/EPAR/awiqli
6. Weekly insulin found safe, effective for Type 2 diabetes. Utsouthwestern.edu. Published July 12, 2023. https://www.utsouthwestern.edu/newsroom/articles/year-2023/july-weekly-insulin-found-safe.html
7. Park J, Kim G, Kim BS, et al. Insulin Fact Sheet in Type 1 and 2 Diabetes Mellitus and Trends of Antidiabetic Medication Use in Insulin Users with Type 2 Diabetes Mellitus: 2002 to 2019. Diabetes & Metabolism Journal. Published online February 7, 2023. doi:https://doi.org/10.4093/dmj.2022.0346
8. American Diabetes Association. Insulin Basics | ADA. diabetes.org. Published 2024. https://diabetes.org/health-wellness/medication/insulin-basics
9. Toft J, Kronborg T, Jensen MH, Rana P, Vestergaard P, Stine Hangaard. Assessment of basal insulin adherence in people with type 2 diabetes in telemonitoring: Post-hoc analysis of novel data modalities including insulin injection data. Diabetes Research and Clinical Practice. Published online April 1, 2025:112191-112191. doi:https://doi.org/10.1016/j.diabres.2025.112191
10. Miller K. Awiqli, a Once-a-Week Insulin Shot for Type 2 Diabetes, Gets FDA Approval. EverydayHealth.com. Published 2026. Accessed March 31, 2026. https://www.everydayhealth.com/diabetes/once-a-week-insulin-shot-is-a-game-changer-for-type-2-diabetes/