Weekly Insulin Icodec Now Available for Type 2 Diabetes

Summary

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Episode Overview

Title: Weekly Insulin Icodec Now Available for Type 2 Diabetes
Date: August 11, 2026
Hosts: Dr. Diana Isaacs & Dr. Natalie Bellini

This episode marks a milestone in diabetes care: the official pharmacy availability of once-weekly insulin icodec (marketed as “Icodec”) for people with type 2 diabetes in the US. Drs. Isaacs and Bellini, speaking live together, offer a clinician-focused breakdown of the latest evidence, practical use-cases, dosing nuances, potential impact on patient burden and satisfaction, and the learning curve ahead for the healthcare community.

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Key Discussion Points & Insights

1. Insulin Icodec Launch: A New Era for Basal Insulin

• Excitement & Context:

  • Dr. Isaacs announces the long-awaited marketplace availability of once-weekly insulin icodec for type 2 diabetes patients in the US, after months of regulatory approval ([00:17]).
  • Dr. Bellini emphasizes its potential for reducing medication burden and improving consistency in settings like aging in place and among patients struggling with daily adherence ([00:35]).

• Clinical Trials & Efficacy:

  • Trials (ONWARDS 1, 3, 5 for insulin-naive; ONWARDS 2 for those switching from daily basal) showed superior A1C reduction and higher satisfaction scores for icodec compared to daily insulins like degludec ([00:53]).
  • Dr. Bellini:

    “I think burden — we always talk about the burden of diabetes. This is going to be really, really nice for a lot of people.” ([01:37])

2. Indication, Type 1 Diabetes, and Safety

• Approved Use:
  • Icodec is approved only for type 2 diabetes at present. Type 1 diabetes studies showed higher rates of hypoglycemia, leading to ongoing trials (including at the Cleveland Clinic) ([01:50]-[02:15]).
  • Dr. Isaacs notes possible off-label, clinical judgment–based use in some type 1 scenarios (e.g., DKA prevention), but specifies that official use is for type 2 diabetes ([01:56]).
  • Dr. Bellini:

    "When we think about that increased risk of hypoglycemia with... type 1 diabetes, maybe when we titrate, the titration just becomes not as aggressive." ([02:33])

3. Dosing and Titration Nuances

• Unique Dosing Paradigm:

  • Because of weekly administration, total weekly dose = daily dose × 7 ([03:07]).
  • Icodec is a U700 concentrated insulin, simplifying the volume of injection ([03:08]-[03:20]).
  • Pen devices deliver doses in 10-unit increments—a learning adjustment for both clinicians and patients:
    • “If you're going to increase from 70 units, your next dose is going to be 80 units. You can't do 71, you can't do 75. You're going to go 10 units at a time...” — Dr. Isaacs ([03:08])
    • Dr. Bellini points out that a 10-unit change per week is “really not much,” amounting to just over 1 unit/day ([04:02]).

• Titration Algorithm (for Insulin-Naïve):

  • Week 1: Start at 70 units
  • Week 2: Assess fasting glucose;
    • If >130 mg/dL, add 20 units
    • If 80-130 mg/dL, stay at same dose
    • If <80 mg/dL, subtract 20 units
      ([04:02]-[05:09])

• Switching from Daily Basal:

  • For established daily basal users, calculate weekly requirement (daily dose × 7), but initial dose should be calculated as daily × 10.5 to reach steady state faster, then dropping to weekly (daily × 7). Adjust to the nearest 10-unit increment ([05:09]-[06:16]).
  • Dr. Isaacs:

    “For the initial dosing, it's recommended to get about 50% more...because it takes longer to get to steady state...So the recommendation is to take the existing dose and actually multiply it by ten and a half and that will get you your first dose.” ([05:09])

• Titration Moving Forward:

  • Dosing adjustments only possible once weekly.
  • Assess and adjust by 10–20% over 2–4 weeks based on fasting and premeal glucose ([06:16]-[07:08]).

4. Clinical Considerations & Practicalities

• Hospitalization Questions:

  • Inpatient management: Most admissions <7 days, so typically, leave icodec unchanged; supplement with correction/IV insulin if needed ([07:08]-[08:21]).
  • Dr. Isaacs:

    “If this is in someone's system...their glucose levels may be better managed. So I think we'll see.” ([08:11])

• Patient Education Needs:

  • Those new to insulin may adapt easily; those transitioning from daily to weekly require tailored education on dosages, units, and the pharmacokinetics ([07:08]).

• Insurance/Access Questions:

  • Not yet clear: Copay cards, Medicare coverage, or if prior authorization (PA) will be needed—details to follow in coming weeks ([08:48]).

5. Reducing Burden and Improving Satisfaction

• Key Benefit:
  • Hosts agree: Once-weekly therapy can meaningfully reduce treatment burden and improve quality of life for a significant subset of people with type 2 diabetes ([08:48]-[09:20]).
  • Dr. Bellini:

    "The reduction in burden, patient satisfaction scores—all those things are much higher with once weekly than daily overall, and so...we need to put this in our pocket now, we need to be able to offer it." ([08:48])

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Notable Quotes & Memorable Moments

• On the magnitude of the shift:

  “We've been talking about once weekly insulin and all the benefits...This I think is going to have a real place in our armamentarium for insulins in general.” — Dr. Natalie Bellini ([00:35])

• Clinical transition for type 1 diabetes:

  “We can always use our clinical judgment—I could for sure think of some use cases where absolutely taking it once a week even in people with type 1 could prevent DKA and be very good. But officially it's approved for type 2 diabetes.” — Dr. Diana Isaacs ([01:56])

• On the education gap:

  “We have to unlearn what our brains were thinking. Right. Which takes a little bit of a minute.” — Dr. Natalie Bellini ([04:02])

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Timestamps for Key Segments

| Segment | Timestamp | |----------------------------------------|------------| | Announcement & Clinical Trials | 00:17–01:55| | Type 1 diabetes discussion | 01:55–02:33| | Dosing and Titration | 02:57–06:16| | Hospital transition considerations | 07:08–08:21| | Insurance & implementation questions | 08:48–09:20|

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Final Thoughts

The arrival of basal insulin icodec promises to revolutionize diabetes management for many with type 2 diabetes, through reduced injection frequency, high efficacy, and improved patient (and caregiver) satisfaction. The hosts anticipate a period of adaptation as clinicians develop day-to-day prescribing skills and educational materials for both providers and patients. Coverage/insurance questions remain, but a major advance in diabetes technology and therapeutics is now pharmacy reality.

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Transcript

[A]

Hello and welcome to another episode of Diabetes Dialogue, Technology, therapeutics and Real World Perspectives. My name is Diana Isaacs. I am joined with my co host Natalie Bellini.

[B]

Live. We can touch each other.

[A]

We're not through the right.

[B]

Exactly.

[A]

And we had to get on here because we're very excited. Hot off the press. Insulin I could act a weekly is officially available via the pharmacy in the United States. It did get approved months ago, but we haven't been able to officially get it until now.

[B]

So excited. Right. We've been talking about once weekly insulin and all the benefits to having something, you know, if you have someone that you don't like, they're just not doing it, they're struggling with it, they need help doing it. I could bring it to someone like my mom and give it once a week and keep it out of her house as she ages in place. So many different ways to just get consistency. People forgetting before they go to bed they and you see it in their downloads. This I think is going to be have a real place in our armatarium for. For insulins in general. So once weekly basal insulin. Let's talk about it. So about 4200 participants across phase 2 and 3 trials. A1C reduction was superior for IODAC among insulin naive participants and that was through these trials called onwards onwards 1, 3 and 5 and those in switching from daily basal insulin in onwards 2. So the latter trial demonstrating improved diabetes treatment satisfaction scores with insulin IODEC versus insulin degladec. This isn't surprising, right? I can do something once a week or every single day. I think that's where we, I think burden. We always talk about the burden of diabetes. This is going to be really, really nice for a lot of people.

[A]

Yeah, I do think is that this is right now approved for type 2 diabetes.

[B]

Absolutely.

[A]

It's actually been studied in type 1 diabetes. However, it did not gain the approval in type 1 diabetes. There was a little bit of higher rates of hypoglycemia and so the FDA wanted to see some additional information and there's actually ongoing trials. Right now we're one of the sites at Cleveland Clinic in fact which is still being studied in type one. So type two is indication now. That doesn't mean, you know, maybe it'll be used off label. We can always use our clinical judgment that, that I could for sure think of some use cases where absolutely taking it once a week even in people with type 1 could prevent DKA and be very good. But officially it's approved for type 2 diabetes.

[B]

And I, I think that when we think about that, that increased risk of hypoglycemia with the type, with people with type 1 diabetes, maybe when we titrate, the titration just becomes not as aggressive. Maybe when we. So let's talk a little bit about dosing with type twos and then maybe we can, we'll, we'll talk a little bit more about that type one population, because I do, honestly, as a clinician, see a very big place for this as well.

[A]

Right. So in terms of dosing, it is very different. Right. Because it's once a week. So it makes sense if someone was going to take 10 units a day. Right. If you're taking it only once a week, you would need 70 units. Right.

[B]

That's easy.

[A]

The equivalent now, it is actually a more concentrated insulin. It is U700 insulin, which I suspect will, you know, people get a little uncomfortable around concentrated insulins, but really it's only available in a pen, so. So you don't really need to worry about the concentration. The reason it's more concentrated is. So the volume is much more comfortable. Absolutely. I mean, if it was U100 insulin, the volume of liquid that would need to be injected at one time, it would just be so much, it would take forever to give that. And so that is why it's more concentrated also, because it's more concentrated and you're giving large amounts. The increment, Instead of being one unit at a time, it's actually going to be 10 units at a time. So that's just important to know. If you're going to increase from 70 units, your next dose is going to be 80 units. You can't do 71, you can't do 75. You're going to go 10 units at a time, which is really not much,

[B]

which is one point something a day when you actually add. So if I say I'm going to take 10 more units and you say 10 more units of basil, but remember, you're dividing that 10 units by seven days, you're at what, 1.2 a day, I mean, or 1.15 a day. So you're not really going up much differently if you go in 10 unit increments. We have to unlearn what our brains were thinking. Right. Which takes a little bit of a minute. So let's talk about it. Insulin naive patients, week one, or people with diabetes, I apologize, week one, 70 units. Week two, 70 units plus the titration. And what titration is, is we're looking at that fasting glucose, if it's greater than 130, we're going to add 20 units. If it's between 80 and 1 30, we're going to leave it alone. Can you that same dose of 70 and then if it's less than 130, I'm sorry, less than 80, we're going to take away 20 units. And remember, taking away 20 units is basically like two to two and a half units a day. You're taking away when you take away 20 at a time. So don't think about it as oh my goodness, you took away 20 units. You took away 20 units over seven days.

[A]

Right. And also, so if someone is coming from an existing long acting insulin, we can still switch them. What we would want to do is take their current dose and you actually would want to, you know, you can either multiply it by seven to get what their dose would be per week, but actually for the initial dosing it's recommended to get about 50% more. And that is just because it takes longer, it has a longer half life, it's going to take longer to get to steady state. So, so if you start off with initially a higher dose, you're gonna get to steady state faster. And so the recommendation is to take the existing dose and actually multiply it by ten and a half and that will get you your first dose. And then from there you can just take seven times that initial dose. So on a practical level, let's say you were taking 10 units a day. So that would be, you know, 10 and a half times. That would be, I got to do the math now. It'd be about 110 unit, it'd be 105. But you're not going to take 105. You got around to either 100 or 110. Are you pulling out your calculator?

[B]

Yeah, I'm like. So you would have to take a long way.

[A]

So depending on someone's current glucose levels. And then after that you'd go back down to 70 units until you're ready to titrate based on those glucose levels. So these are going to be some of like the new things, you know, we're going to figure out as we go along and figure out how to adust adjust this. We'll need new titration algorithms, kind of like the one you just mentioned because you know, in the past we're used to, okay, every three to four days we could increase by two, decrease by two. Commonly we make adjustments 10 to 20% at a time. And I think it'll be similar for this too. Absolutely. Thinking that, you know, obviously you're not going to make dose adjustments more than once a week because you can't. Right. You're only taking it once a week. But I think in a lot of cases, we'll take a look at the last two to four weeks and then we may adjust it 10 to 20%. 20% based on what those fasting and premal glucose levels look like.

[B]

So there is going to be a little bit of learning in this for all of us as we prescribe this, as we talk about this. Someone brought up the other day, what are we going to do when we go to the hospital? And actually, interestingly, people are like, leave it alone. Right. So unless you're there seven days, the average hospital admit, I think is less than 3. Right. Now you may do nothing at all. You know, if we need to use IV glucose to hold it, somebody steady during fasting, we, we may have to do that. But like, truthfully, if you're on the right dose of basal insulin, it shouldn't be covering meals, it shouldn't be dropping you overnight, it shouldn't be doing any of these things. So there is going to be some learning curve there. There's going to be some learning curve with people, I think insulin naive people, won't it? It doesn't matter to them. They don't know 10 units versus 38 units versus 125 units. Right. So that people on insulin and starting and converting from basal insulin, where they're taking, you know, 10 or 20 units a day to say now you're going to take 70 or 140 units once a week, that education is going to be a little bit different. Right.

[A]

Actually, you know, I'm hopeful that actually the transition to the hospital will be okay because if this is in someone's

[B]

system, assuming it actually might improve their hospitalizations. Right.

[A]

Like actually it would be important to try to find out when the last dose was. But yeah, I mean, they're going to have basal insulin in their system. So in theory, all you'd really need would be that correction dose. The correction scale, you monitor their glucose, give correction as needed. But yeah, it may actually be easier. Their glucose levels may be better managed. So I think we'll see. Of course we need to follow them closely, make sure they're not experiencing hypoglycemia as with any insulin. But I, you know, it actually might be great. Right?

[B]

Exactly. So again, we kind of go back and forth. There's going to be a little bit of education but I think the reduction in burden patient satisfaction scores all those things are much higher with once weekly than daily overall and so to me it's like we need to put this in our pocket now we need to be able to offer it things that we don't know yet as we're now available in pharmacy is where is there a copay card what about Medicare those kinds of things we'll know in the next handful of weeks to months right

[A]

like would expect maybe a PA is required but if you can you can think of a lot of use scenarios where if there's caregivers involved this once weekly or really medication taking behaviors that are suboptimal this is going to really help. So yeah we're very excited we're very excited finally available and with that we thank you for tuning in to this quick update and that wraps up this episode of diabetes dialogue Technology therapeutic than real world perspectives.

[B]

Thanks everyone.