Converting from Tresiba 58 Units Daily to Awiqli (Insulin Icodec)

Start with 350 units of Awiqli (insulin icodec) once weekly as the equivalent replacement for 58 units daily of Tresiba (insulin degludec).

Conversion Calculation

The conversion ratio is approximately 7:1 when switching from daily degludec to weekly icodec 1, 2.
For 58 units/day of Tresiba × 7 days = 406 units total weekly basal insulin exposure 3.
Clinical trials demonstrate that weekly icodec doses are roughly equivalent to the total weekly dose of daily degludec, though slightly lower doses of icodec often achieve superior glycemic control 1, 2.
A reasonable starting dose is 350 units of Awiqli once weekly (approximately 6× the daily Tresiba dose), which falls within the range used in ONWARDS trials 1, 2.

In the ONWARDS 2 trial, patients switching from once-daily basal insulin (including degludec) to weekly icodec achieved superior HbA1c reduction (estimated treatment difference -0.22 percentage points, p=0.0028) 1.
The ONWARDS 3 trial in insulin-naive patients demonstrated that weekly icodec was superior to daily degludec for HbA1c reduction (estimated treatment difference -0.2 percentage points, p=0.002) 2.
Across multiple phase 3 trials involving over 4,200 participants, icodec showed similar or superior efficacy to once-daily basal insulin analogues 4.

Adjust the weekly icodec dose by 10-20 units once weekly based on fasting glucose patterns over the preceding week 3.
Target fasting glucose of 80-130 mg/dL (4.4-7.2 mmol/L) 3, 5.
If fasting glucose is consistently ≥180 mg/dL, increase by 20 units weekly 3.
If fasting glucose is 140-179 mg/dL, increase by 10 units weekly 3.
If hypoglycemia occurs or fasting glucose <80 mg/dL on multiple occasions, reduce dose by 10-20% 3, 5.

Hypoglycemia rates are numerically higher with weekly icodec compared to daily degludec, though overall rates remain low (<1 event per patient-year in type 2 diabetes trials) 1, 2.
In ONWARDS 2, combined level 2 or 3 hypoglycemia rates were 0.73 vs 0.27 events per patient-year for icodec vs degludec (estimated rate ratio 1.93, though not statistically significant) 1.
In ONWARDS 3, hypoglycemia rates were statistically higher with icodec from week 0-26 (0.35 vs 0.12 events per patient-year, p=0.01) 2.
Monitor fasting glucose daily during the first 4-6 weeks after conversion to assess adequacy of dosing 3.

Modest weight gain was observed with icodec in switching trials, with an estimated treatment difference of +1.70 kg compared to degludec at 26 weeks 1.
In insulin-naive patients, weight gain was similar between icodec and degludec (no significant difference) 2.

If the weekly icodec dose exceeds 0.5 units/kg/day equivalent (approximately 245 units weekly for a 70 kg patient) and HbA1c remains above target, consider adding prandial insulin rather than continuing to escalate basal insulin 3, 5.
Signs of overbasalization include basal dose >0.5 units/kg/day, bedtime-to-morning glucose differential ≥50 mg/dL, hypoglycemia, and high glucose variability 3.

Continue metformin unless contraindicated when switching to weekly icodec, as this combination provides superior glycemic control with reduced insulin requirements 3.
Consider discontinuing sulfonylureas to reduce hypoglycemia risk 3.