Prefer to listen? Check out my podcast here:

Insulin is used to treat diabetes. Long acting insulin, also called basal insulin, is typically given once per day. Some people have trouble remembering to take their basal insulin every day. Also, while the needles used for insulin injections are very small, sometimes the needle pokes are a barrier to taking insulin every day. To address these issues, once-weekly insulin icodec (trade name Awiqli, pronouced ‘a-weekly’) is now approved and available in Canada for the treatment of diabetes in adults. Canada is the first country in the world to have this new insulin available.

In evaluating weekly insulin, two key things we want to know are:

  • does it control diabetes as well as existing once daily basal insulins?
  • is there any higher risk of hypoglycemia (low blood sugar) compared to existing once daily basal insulins?

In people with type 2 diabetes new to insulin in the ONWARDS-1 study, in comparison to insulin glargine U-100 (Lantus), hemoglobin A1C was marginally lower (by 0.2%) with icodec. Low blood sugars were infrequent in both groups, with a (non significant) trend towards a little more frequent low sugars with icodec. If 100 people were treated for 1 year, with icodec, 29 people would have a a blood sugar <3 mmol/L, vs 15 people with glargine. There was 1 severe low (requiring assistance from another persion) vs 3 with glargine.

In the ONWARDS-3 study, weekly insulin icodec was compared to daily insulin degludec (Tresiba) in people with type 2 diabetes new to insulin therapy. Again the A1C was just marginally (0.2%) lower with icodec . During the 26 week treatment period, there were 0.35 low sugars (<3 mmol/L) per patient year, vs 0.12 per patient year with degludec, which was statistically significant, though these overall rates of hypoglycemia were very low. Two people in the degludec arm had severe lows, with none in the icodec arm. There was no difference in weight between the two groups, with both groups gaining around 5lb during the study.

In the ONWARDS-2 study, people with type 2 diabetes already on basal insulin were randomized to once weekly icodec vs once daily degludec. Again there was a 0.2% lower A1c with icodec than degludec, and a non significant trend towards a little higher risk of lows with icodec (again the overall numbers were extremely low). There was a little more weight gain with icodec (1.4kg) vs 0.3kg weight loss with degludec. Treatment satisfaction reported by patients was higher with weekly icodec than with daily degludec.

The ONWARDS-6 study looked at the effect of icodec vs degludec in people with type 1 diabetes. The study was open-label, meaning that patients and study investigators knew which insulin the patient was randomized to take. These people were all taking both basal (long acting) and mealtime insulin prior to enrolment in the study (ie typical type 1 diabetes insulin treatment regimes). There was no difference in A1C at the end of the 26 week study. There was a statistically signficantly higher risk of combined clinically signficant and severe hypoglycemia (19.9 events per patient-year with icodec vs 10.4 events per patient-year with degludec). Interestingly, the treatment satisfaction scores were higher with degludec, perhaps reflecting that these people with type 1 diabetes were missing the flexibility of adjusting their basal insulin on a daily basis to fit their lifestyle or activity level. Icodec has not been studied in new type 1 diabetes patients being newly started on insulin.

As insulin icodec is given once a week, the doses given in one injection sound high – 7 times higher than a daily dosing regimen, to be exact. For traditional daily basal insulins in type 2 diabetes, the starting dose is usually 10 units daily – with icodec, the recommended starting dose (per the product monograph) is 70 units weekly. Adjustments in dose are made by 10 unit increments, and adjustments in dose can be made once a week. In the clinical trials, icodec was adjusted by 20 units per week as needed to obtain target fasting blood sugar (equivalent to 3 units per day). The icodec pens are built to allow for up to 700 units to be given in a single weekly injection (equivalent to 100 units per day).

To switch patients from their current basal insulin to icodec, the corresponding weekly icodec dose is the previous basal dose multipled by 7 (as it is a weekly insulin). However, because icodec is such a long acting insulin, it takes time to see its effect. Therefore, depending on a person’s glucose control and history of hypoglycemia, for the first dose only, per the product monograph, a one-time additional dose of 50% of the calculated icodec dose can be added (so, the first transition dose can be 10.5 times the person’s usual daily basal insulin dose).

Insulin icodec has not been studied in kids, nor in pregnant/breastfeeding women, and therefore must not be used (is contraindicated) in these patient groups. No overall differences in safety or effectiveness have been seen in people age 65 or older; experience is limited in people age 75 and up. NOTE: Basal insulin DOES NOT replace mealtime insulin needs.

BOTTOM LINE: Once-weekly basal insulin icodec provides similar blood sugar control to once-daily basal insulins, with a little higher risk of low blood sugars in type 2 diabetes, and a higher risk of low sugars in type 1 diabetes. This insulin may be preferred by patients who wish to reduce basal insulin injections from one per day to one per week, and may improve compliance in people who would/have trouble remembering to take their basal insulin every day.

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

Share this blog post using your favorite social media link below!

Follow me on X/twitter! @drsuepedersen

www.drsue.ca © 2024