Practice Signal
This review helps pharmacists manage patients who arrive on once-weekly icodec or efsitora, from medication reconciliation and continue-versus-convert decisions to perioperative planning, using ONWARDS and QWINT hospitalization data and the ADA 2026 inpatient standards.
Most patients on once-weekly icodec or efsitora can stay on their weekly dose through a routine admission: in trial hospitalizations 97.8% of icodec cases needed no added daily basal insulin and glucose control was stable before and after. Confirm the last dose date and weekly units, cover meals and corrections instead of stacking a daily basal dose, and plan elective major surgery weeks ahead, because a weekly dose cannot be taken back.
Two once-weekly basal insulins now have FDA approval for adults with type 2 diabetes: insulin icodec (Awiqli, approved March 2026, 700 units/mL) and insulin efsitora alfa (Onswik, approved September 24, 2026, U-500 and U-1000 KwikPens, half-life about 17 days). Neither is approved in the US for type 1 diabetes. In outpatient trials both matched or slightly beat daily basal insulin on HbA1c. In QWINT-2, efsitora lowered HbA1c by 1.26 points versus 1.17 with degludec in insulin-naive patients, with no severe hypoglycemia versus 6 events on degludec. ONWARDS 1 and ONWARDS 2 showed small HbA1c advantages for icodec over glargine and degludec. QWINT-3 showed noninferiority to degludec in patients already on basal insulin.
These patients will start showing up on hospital admission lists, and most hospitals will not stock either product. The inpatient question is different from the clinic question. A daily basal dose can be cut 20 to 25% the night before surgery or skipped tonight. A weekly dose already given keeps working for days, and nothing on the floor can pull it back. The only inpatient data come from post hoc analyses of trial participants. Across ONWARDS 1-6, 7.0% of icodec and 7.2% of comparator participants were hospitalized, median stays were 5 and 6 days, and 97.8% of icodec hospitalizations needed no added daily basal insulin. Across QWINT 1-4, 9.2% of efsitora and 7.1% of comparator participants were hospitalized (p=0.17), median stay was 5.0 days in both arms, and HbA1c and fasting glucose were similar before and after admission.
The practical picture: in a typical short admission the weekly dose already on board covers basal needs, and the work shifts to verifying what the patient took and when, covering meals and corrections, and planning ahead for anything that will change intake for more than a day.
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