Insulin Icodec Dosing Strategies for Type 2 Diabetes

Once-weekly basal insulin is reshaping the treatment landscape for type 2 diabetes (T2D), offering an alternative to the daily injection burden long associated with insulin therapy. Reducing dosing frequency from seven injections a week to one carries implications for adherence, caregiver-assisted administration, and treatment satisfaction.

On a recent episode of Diabetes Dialogue, hosts Diana Isaacs, PharmD, and Natalie Bellini, DNP, discussed practical strategies for initiating and titrating insulin icodec (Awiqli), now available at US pharmacies following its Food and Drug Administration approval for adults with type 2 diabetes. The conversation centered on dosing mechanics for insulin-naive patients and those switching from daily basal insulin, along with considerations for off-label use in type 1 diabetes.

Watch the full episode discussing the commercial availability of Awiqli here.

For insulin-naive patients, initiation begins with a fixed dose of 70 units once weekly, titrated according to fasting glucose readings. A fasting glucose above 130 mg/dL prompts a 20-unit increase, readings between 80 and 130 mg/dL maintain the current dose, and readings below 80 mg/dL trigger a 20-unit reduction. Because dosing adjustments occur in 10-unit increments, a 20-unit change corresponds to roughly a 2 to 3-unit daily equivalent, a smaller shift than the raw numbers suggest.

Patients transitioning from a daily basal insulin require a different calculation. The initial weekly dose is derived by multiplying the current daily dose by 10.5, a strategy intended to reach steady state faster given icodec's roughly 7-day half-life. Subsequent maintenance doses are calculated by multiplying the original daily dose by seven, with titration resuming once steady state is achieved.

Insulin icodec is formulated as a U-700 concentration to limit injection volume, though it is dispensed only in a prefilled pen, minimizing dosing-error concerns tied to concentrated insulins. The agent has not received FDA approval for type 1 diabetes, following advisory committee concerns about elevated hypoglycemia rates among patients with type 1 diabetes; additional trials, including a site at Cleveland Clinic, remain ongoing.

Collectively, these dosing considerations underscore a learning curve clinicians will need to navigate as once-weekly basal insulin enters routine practice. Beyond glycemic outcomes, insulin icodec's convenience profile may prove especially valuable for older adults and patients reliant on caregiver-administered insulin, positioning it as a meaningful addition to the basal insulin armamentarium for type 2 diabetes.

Editors’ Note: Isaacs reports disclosures with Dexcom, Abbott, Lilly, Novo Nordisk, Medtronic, Insulet, and others. Bellini reports disclosures with Abbott Diabetes Care, MannKind, Povention Bio, and others.

References

1. Novo Nordisk. Novo Nordisk's Awiqli, the first once-weekly basal insulin for adults with type 2 diabetes, now available in the US. PR Newswire. August 11, 2026. Accessed August 12, 2026. https://www.prnewswire.com/news-releases/novo-nordisks-awiqli-the-first-once-weekly-basal-insulin-for-adults-with-type-2-diabetes-now-available-in-the-us-302847645.html