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Weekly Insulin: Practical Considerations
Weekly Insulin: Translating the Latest Evidence Into Practical Considerations

Released: September 26, 2023

Expiration: September 26, 2024

Steven V. Edelman
Steven V. Edelman, MD
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Key Takeaways
  • Clinical trials have shown that weekly basal insulin is safe, and the incidence of hyperglycemia is no different from second-generation daily basal insulins.
  • Weekly basal insulin may improve adherence and may make life easier for patients with special needs. 

Benefits and Disadvantages of Weekly Insulin
I can see a lot of benefits from the development and application of once-weekly basal insulins when they become available. Both weekly basal insulins in development, insulin icodec and insulin efsitora alfa, have excellent pharmacokinetic (PK) and pharmacodynamic (PD) characteristics. Any medication for type 2 diabetes (T2D) that is given once a week may improve adherence and make life easier for patients with special needs. It also increases the opportunity to combine insulin with other medications such as a once-weekly glucagon-like peptide-1 (GLP-1) receptor agonist.

I believe there will be flexibility in the dosing of once-weekly basal insulin. For example, a person with T2D may be able to take it 2 days earlier and 2 days later than their typical time, which adds more flexibility. However, this possibility requires confirmation once we have the prescribing information instructions. 

Based on the PKPD characteristics, I think once-weekly basal insulin could make life easier for patients—and that is the bottom line. Anything that is easier for patients is going to improve adherence and persistence. 

I think the biggest concern many people have is hypoglycemia when there are unusual circumstances. For example, if someone becomes unable to take things by mouth because of a car accident, or they are in the intensive care unit for a serious medical illness and they cannot eat, this affects insulin requirements. If you have to stop the insulin for any reason, it will persist for a while before it clears the patient’s system. Weekly basal insulins will have to be studied in those situations.

Clinical trials have shown that weekly basal insulin is safe, and the incidence of hyperglycemia is no different from second-generation daily basal insulins. It is also important to remember that when individuals get sick, their basal insulin requirement may not go down, but in fact, it may go up, and so this may not be as big of an issue as we think. 

Fitting Weekly Basal Insulin Into the Treatment Paradigm
If I were seeing a patient today and had a choice of weekly vs daily basal insulin, there is no question—I would choose weekly basal insulin. Why not make life simpler for the patient? I do not think any provider would give their patient daily basal insulin unless there was a huge price difference. I am assuming that there is price equality here. It is important to remember that the initiation and titration of once-weekly basal insulin involves a higher dose and the adjustment on the loading dose, at least for icodec. For successful use of once-weekly basal insulin, an education program for both patients and providers will be necessary.

Weekly Insulin for Special Populations? 
When I think of where basal insulin could be used, and thinking about special populations, there is no question that people who may have a hard time caring for themselves, those with disabilities or in nursing homes, could benefit greatly. What happens in these situations is people often do not get their insulin as prescribed. For example, there may be 2 or 3 days of missed doses if the caretaker cannot come over to the house, or there could be an administration error by a healthcare worker resulting in an incorrect dose.

Studies will have to be done on use during pregnancy and in pediatric patients; it is possible that these populations of patients will benefit as well.

In Summary
Clinical trials have shown weekly basal insulin to be safe and effective. I think it has tremendous potential to improve diabetes control, based on several characteristics, including the PKPD of the insulin. I would like to emphasize that because this is a new insulin in a way, and because it is going to be starting off with what will likely appear to patients to be high doses since they are dosed based on weekly requirements, there is going to have to be a tremendous education campaign for providers and for patients. 

Currently, while access is limited between patients and providers, self-titration of insulin is key.  Anything that we can do to improve that and support patients as they initiate and titrate their weekly basal insulin will help with the future success. 

Your Thoughts?
In your clinical practice, which patients with T2D will benefit most from once weekly basal insulin becomes available? Answer the polling question and join the conversation by adding a comment in the discussion section.

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In your practice, which patients with type 2 diabetes will likely benefit most from once-weekly basal insulin when it becomes available?

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