Weekly Insulin Injections: Initiating Once-Weekly Insulin Icodec
For insulin-naïve patients with type 2 diabetes who prefer fewer injections, start once-weekly insulin icodec at 70 U/week, administered subcutaneously on the same day each week, with weekly dose adjustments targeting fasting plasma glucose of 80-130 mg/dL. 1
Starting Dose Recommendations
The standard starting dose is 70 U/week for most insulin-naïve patients, which is equivalent to 10 U/day of traditional basal insulin 1. However, individualize based on specific patient characteristics:
Dose Modifications for Special Populations
- Chronic kidney disease with reduced GFR or low BMI: Start at 50 U/week 1
- Asian patients: Consider 30-70 U/week range 1
- China label: 70 U/week standard
- Japan label: 30-70 U/week based on individual condition
Administration Protocol
- Timing: Same day each week, any time of day 1
- Injection sites: Abdomen, thigh, or deltoid (rotate to prevent lipodystrophy) 1
- Concentration: 700 U/mL (seven times more concentrated than standard 100 U/mL insulins) 1
Titration Strategy
Adjust dose weekly based on fasting plasma glucose measurements 1:
- Target FPG: 80-130 mg/dL 1
- Adjustment increments: ±21 units/week provides the best balance between glycemic control and hypoglycemia risk 2
- Steady state: Achieved in 3-4 weeks without loading dose, or 2-3 weeks with a 50% loading dose 1
Monitoring Requirements
Critical during initial weeks 1:
- Frequent fasting plasma glucose measurements for accurate dose adjustments
- Continuous glucose monitoring (CGM) strongly recommended, especially during:
- Initial transition weeks
- Changes in physical activity
- Illness episodes
Efficacy Evidence
The ONWARDS clinical trial program demonstrates robust efficacy 1:
- ONWARDS 1: Superior HbA1c reduction versus glargine U100 (-1.55% vs -1.35%, p=0.02) at 52 weeks 3
- ONWARDS 3: Superior HbA1c reduction versus degludec (-0.2 percentage points, p=0.002) at 26 weeks 4
- Time in range: Significantly improved (71.9% vs 66.9% with glargine U100) 3
Safety Profile
Hypoglycemia rates are comparable to daily basal insulins 1:
- Combined clinically significant or severe hypoglycemia: 0.30 events per patient-year with icodec vs 0.16 with glargine U100 3
- Level 2 hypoglycemia (<54 mg/dL): Low across trials (0.05-0.38 events per patient-year) 2
- No severe hypoglycemia episodes in phase 2 trials 2, 5
- Adverse event profile similar to daily basal insulins with no new safety signals 1
Important Caveats
Exercise caution in patients with 1:
- History of severe hypoglycemia or hypoglycemia unawareness
- Recent cardiovascular events (within 180 days)
- Chronic heart failure
- Severe renal impairment (though ONWARDS 5 permitted this)
Concomitant Medications
Insulin secretagogues (sulfonylureas, meglitinides): Consider dose reduction or discontinuation when initiating icodec to minimize hypoglycemia risk 1
Key Advantages Over Daily Insulin
- Reduced injection burden: 52 injections/year vs 365 injections/year
- Similar or superior glycemic control compared to once-daily basal insulins 1
- Comparable safety profile with low hypoglycemia rates 1
- Flexible weekly dosing may improve adherence and treatment satisfaction 1
Regulatory Status
Approved for type 2 diabetes treatment in the EU, Australia, Brazil, Canada, Japan, India, South Korea, and China 1