Wicked Good Cardiometabolic Chat: Once-Weekly Insulin Management

Although reducing basal insulin injections from 365 to 52 per year could substantially lessen treatment burden, administering an entire week of insulin at one time also introduces important questions about patient selection, dosing, monitoring, and medication safety.

In this episode of Wicked Good Cardiometabolic Chat, hosts Hailey Choi, PharmD, BCACP, CDCES, and Jennifer Goldman, PharmD, CDCES, BC-ADM, FCCP, professors of pharmacy practice at the Massachusetts College of Pharmacy and Health Sciences, examine the evolving once-weekly insulin landscape, including insulin icodec and insulin efsitora alfa.

More specifically, they break down the ONWARDS and QWINT clinical trial programs, explaining how these therapies differ from daily basal insulin and what the available evidence may mean for adults with type 2 diabetes (T2D).

Goldman and Choi then explore the practical issues pharmacists are likely to encounter, including initiating once-weekly insulin, transitioning from daily basal insulin, distinguishing a one-time initial conversion dose from the maintenance dose, managing missed doses, and preventing confusion with other weekly injectables.

Most importantly, this episode focuses on the pharmacist’s role in translating innovation into safe patient care. Once-weekly dosing may reduce injection burden, but its success will depend on careful patient selection, precise instructions, effective teach-back, glucose monitoring, and timely follow-up.

More on Weekly Insulin and the Pharmacist’s Role

Although both once-weekly options provide a prolonged basal effect, they achieve this through distinct pharmacological mechanisms. Insulin icodec, commercially available as of August 2026, is an acylated human insulin analog with strong, reversible albumin binding. Meanwhile, insulin efsitora alfa remains investigational but utilizes a fusion protein combining a single-chain insulin variant with an IgG2 Fc domain.

Pharmacists must treat "once-weekly" strictly as a dosing interval rather than a statement of therapeutic interchangeability. Each product carries unique device designs, titration algorithms, and missed-dose instructions that must not be conflated.

US approval for icodec is restricted to adults with T2D. The phase 3 ONWARDS program demonstrated noninferior A_1c reduction compared with daily basals. However, the type 1 diabetes trial (ONWARDS 6) revealed significantly higher rates of severe hypoglycemia, reinforcing why clinical use must stay strictly within the FDA-approved indication.

The transition from daily basal insulin to once-weekly icodec represents a major counseling and verification checkpoint for pharmacists. For insulin-naive patients, the starting dose is simple: 70 units subcutaneously once weekly. However, switching from a daily regimen requires a one-time loading dose to reach a steady state quickly.

Crucial Pharmacist Safeguards and Patient Education

Pharmacists are central to preventing high-consequence errors during this transition. The risk of mix-ups with daily insulins or other weekly injectables, such as GLP-1 receptor agonists like semaglutide, is elevated. As our hosts explain, pharmacists should employ robust teach-back techniques to ensure patients can identify their medications, understand their purpose, and more. Additionally, patient education must cover the strict 4-day missed-dose window and the absolute necessity of keeping rescue glucagon on hand.

Watch the full episode for a practical, evidence-based discussion on what once-weekly basal insulin means for pharmacists and the patients they serve.

In Wicked Good Cardiometabolic Chat, a podcast offering from Drug Topics, Goldman and Choi aim to empower pharmacists with evidence-based insights into various cardiometabolic topics. All new episodes of Wicked Good Cardiometabolic Chat will be available in a video format via DrugTopics.com. Check out our most recent episode: Identifying and Managing MASH.