Two Once-Weekly Insulins Are Here: Which Patient Gets Which?

The arrival of Onswik, a new once-weekly basal insulin, gives healthcare professionals another treatment option for adults with type 2 diabetes. Following the FDA approval of Awiqli (insulin icodec-abae) in March 2026, Onswik (insulin efsitora alfa-gobe) received approval in September 2026. Both medications reduce basal insulin injections from seven per week to one. However, fewer injections do not automatically mean better treatment. Clinicians must now consider a more important question: Which patients will benefit most from each therapy, and when is daily basal insulin still the better choice?

Table of Contents

1. Onswik vs. Awiqli: Comparing Two Once-Weekly Basal Insulins
2. Which Patients Are Best Suited for Weekly Basal Insulin?
3. Switching From Daily Basal Insulin: Dosing and Hypoglycemia Risks
4. Patient Counseling: Making Weekly Insulin Safer and More Practical
5. Conclusion
6. Frequently Asked Questions

Onswik vs. Awiqli: Comparing Two Once-Weekly Basal Insulins

The FDA approval of Onswik introduces a second weekly basal insulin for adults with type 2 diabetes. Although both products provide prolonged glucose control, their dosing schedules and administration requirements differ.

Onswik, developed by Eli Lilly, contains insulin efsitora alfa-gobe. Meanwhile, Novo Nordisk's Awiqli contains insulin icodec-abae. Both are long-acting insulin analogs designed to provide basal coverage throughout the week.

Clinical evidence supports their effectiveness compared with daily basal insulin. In the QWINT clinical development program, Onswik produced A1C reductions comparable to daily insulin glargine or insulin degludec across four randomized studies. Similarly, Awiqli demonstrated effective glucose lowering in the ONWARDS clinical program.

However, these findings do not establish that one weekly insulin is clinically superior to the other. No direct head-to-head randomized trial has established which product provides better outcomes for comparable patients.

Their formulations also differ. Onswik is available in U-500 and U-1000 KwikPens, while Awiqli uses a U-700 FlexTouch pen. Consequently, clinicians must understand each product's dosing instructions rather than treating the two insulins as interchangeable.

The FDA's Onswik approval announcement provides additional information about its clinical effectiveness and safety.

Which Patients Are Best Suited for Weekly Basal Insulin?

Choosing the right patients for once-weekly basal insulin therapy with Onswik or Awiqli involves more than reviewing A1C results. Clinicians should also assess treatment habits, hypoglycemia history, glucose variability, and the patient's ability to manage weekly injections.

Adults who frequently miss daily basal insulin doses may benefit from fewer injections. Similarly, individuals experiencing injection fatigue may welcome a simpler schedule. However, weekly dosing does not guarantee better medication adherence.

For patients beginning insulin therapy, weekly options may reduce concerns about daily injections. Nevertheless, fewer injections do not eliminate the need for regular glucose monitoring or ongoing treatment adjustments.

Patients with predictable routines and relatively stable insulin requirements may be suitable candidates. In contrast, individuals experiencing frequent glucose fluctuations, recurrent hypoglycemia, or rapidly changing insulin needs require closer evaluation.

Older adults may appreciate reduced injection frequency. However, clinicians should carefully consider cognitive function, visual limitations, caregiver support, and the possibility of dosing errors.

Importantly, patients already achieving excellent control with daily basal insulin may have little reason to switch. Treatment satisfaction, affordability, insurance coverage, and access remain important considerations.

For additional background, Diabetes in Control previously examined the development of once-weekly insulin icodec and its potential role in simplifying diabetes treatment.

Ultimately, the best candidate is someone who can follow a weekly schedule safely while maintaining consistent glucose monitoring.

Switching From Daily Basal Insulin: Dosing and Hypoglycemia Risks

Switching from daily insulin to weekly treatment requires careful planning. Although both medications provide prolonged basal coverage, their initial dosing protocols differ significantly.

For insulin-naive adults, Onswik offers a fixed starting regimen of 100 units weekly, with later adjustments, or a flexible regimen involving a one-time 300-unit starting dose followed by 100 units in week two. These are alternative initiation approaches, and subsequent dosing must follow the prescribing information.

Awiqli, by comparison, has a recommended starting dose of 70 units weekly for insulin-naive adults.

For patients transitioning from daily basal insulin, Onswik's labeled one-time starting dose generally uses three times the previous total daily basal dose multiplied by seven. However, additional conversion rules apply to certain basal insulins, and clinicians may consider omitting the loading dose in specified circumstances.

Awiqli uses a different approach. Its first dose generally equals 1.5 times the previous daily basal dose multiplied by seven, followed by a maintenance calculation based on seven times the daily dose.

Consequently, conversion protocols must never be transferred between products. Clinicians should verify the current prescribing information and individualize every transition.

Hypoglycemia remains a central concern. Because these medications remain active for extended periods, the effects of dosing decisions can persist longer than with many daily insulin regimens.

Furthermore, Onswik's full glucose-lowering response to a dose adjustment may take approximately four weeks. This makes premature dose escalation particularly concerning.

Clinicians should review continuous glucose monitoring or structured glucose readings when appropriate, assess concurrent medications, and reinforce hypoglycemia management.

The official Onswik prescribing information outlines conversion schedules, missed-dose instructions, and important safety precautions.

Patient Counseling: Making Weekly Insulin Safer and More Practical

Helping patients use Onswik safely and effectively starts with clear education about weekly insulin injections. While reducing injection frequency may simplify treatment, it also creates new responsibilities for patients and caregivers.

First, patients must understand that weekly basal insulin is not simply a weekly version of their previous daily dose. Each product requires its own prescribed dose and injection schedule.

Clinicians should demonstrate pen operation, explain how to verify the displayed dose, and confirm understanding through teach-back. Because these formulations contain concentrated insulin, patients should never attempt to calculate injection volumes or withdraw insulin from the pen using a syringe.

Additionally, patients need clear instructions for missed injections. Although both products allow a missed dose to be administered within four days, their instructions for returning to a regular schedule differ.

Patients should also understand that weekly insulin does not replace mealtime insulin when that treatment remains necessary. Regular glucose monitoring continues to be essential, especially during treatment transitions.

Importantly, neither product should be selected solely for convenience when safety concerns outweigh potential benefits.

A useful counseling conversation should include treatment expectations, warning signs of hypoglycemia, medication storage, injection-site rotation, and whom to contact when glucose patterns change.

Patients seeking individualized treatment advice can consult qualified healthcare professionals through resources such as Healthcare.pro.

For clinicians, the goal is not simply reducing injection frequency. Instead, it is matching the treatment plan to the patient's clinical needs, preferences, and ability to use insulin safely.

Conclusion

With Onswik joining Awiqli as another once-weekly basal insulin option, clinicians have more flexibility when tailoring treatment for adults with type 2 diabetes. Both treatments offer fewer basal injections while maintaining effective glucose control in clinical trials.

However, choosing between them requires careful attention to dosing protocols, hypoglycemia risks, patient preferences, and treatment stability.

Daily basal insulin will remain appropriate for many patients. Ultimately, personalized treatment selection, rather than injection frequency alone, should guide clinical decisions.

Frequently Asked Questions (FAQs)

1. What is the difference between Onswik and Awiqli?

Onswik contains insulin efsitora alfa-gobe, while Awiqli contains insulin icodec-abae. Both provide once-weekly basal insulin treatment, but their formulations, starting doses, and conversion instructions differ.

2. Is Onswik more effective than Awiqli?

Current evidence does not establish that Onswik is superior to Awiqli. Both demonstrated effective glucose lowering compared with daily basal insulin in separate clinical programs.

3. Can patients switch directly from daily insulin to Onswik?

Yes. Eligible adults can transition from daily basal insulin under medical supervision. However, clinicians must follow Onswik-specific dosing instructions and closely monitor glucose during the transition.

4. Does once-weekly insulin increase hypoglycemia risk?

Hypoglycemia remains a significant risk with both products. Individual risk depends on insulin dosing, glucose patterns, concurrent medications, and other clinical factors. Close monitoring is especially important during treatment changes.

5. Should all adults with type 2 diabetes switch to weekly insulin?

No. Weekly insulin may benefit patients who struggle with daily injections, but stable patients doing well on daily therapy may not need to change. Treatment decisions should remain individualized.

This content is not medical advice. For any health issues, always consult a healthcare professional. In an emergency, call 911 or your local emergency services.