Once Weekly Insulin For Treatment of Diabetes?

In our efforts to make it easier for people to manage their diabetes, there is a movement towards developing injectable treatments that need to be given less often. Although the needles used these days are very small, giving injections every day can be hard to remember, and patients often ask me if there are any options for less frequent injections. For people who have never been on insulin, the idea of injecting every day can present a barrier to getting started. While we have had success in developing weekly version of GLP1 injections for years (with dulaglutide (Trulicity) and semaglutide (Ozempic)), all currently available basal insulins are given daily.

Just published in the New England Journal of Medicine is a study of a once weekly insulin under development, called isodec.

This was a 26 week randomized, double blind, phase 2 trial comparing the efficacy and safety of once weekly isodec insulin to once daily U100 glargine (Lantus) insulin. There were 247 people in this study, all with type 2 diabetes, A1C of 7-9.5% (baseline A1C 8%), on metformin +/- DPP4 inhibitor, and had not previously been using insulin. The starting dose of icodec insulin was 70 units (U) weekly, and starting dose of glargine was 10 U daily. Insulin doses were adjusted weekly to achieve target fasting blood sugar.

At the end of the study, the diabetes control was similar in both groups, with A1C of 6.7% in the icodec group and 6.9% in the glargine group. The average isodec dose at the end of the study was 33 U per day, vs 41 U per day in the glargine group. People in the isodec group had better blood sugars over the course of the day at the end of the study, as well as 78 minutes more per day spent in tight control (3.9-7.8 mmol/L). There was no difference between groups in clinically significant or severe hypoglycemia (low blood sugar), though mild hypoglycemia was seen more commonly in the isodec group (5.1 events per patient-year) than the glargine group (2.1 events per patient-year). The authors suggest that the higher number of mild low sugars in the isodec group could perhaps be avoided by targeting a slightly higher fasting blood sugar, and increasing the weekly insulin in smaller increments in future studies. There was no difference in weight gain between the two groups (both groups gained about 1.5kg). There were no other differences in safety or tolerance.

BOTTOM LINE: Once weekly insulin could be a game changer in diabetes care, as it would reduce the number of injections per year from 365 to just 52. While more study needs to be done on isodec insulin, these results are promising that once weekly insulin could one day become a reality. Icodec is being studied in people with type 1 diabetes as well.

Disclaimer: I receive honoraria as a continuing medical education speaker and consultant from the makers of isodec insulin (Novo Nordisk).

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