Natalie Bellini, DNP, FNP, BC-ADM, CDCES

Switching patients from daily basal insulin to once-weekly insulin icodec (Awiqli) requires a distinct dosing calculation clinicians have not previously had to apply, given the agent's extended half-life and slower time to steady state. Getting the conversion right matters for glycemic stability during the transition period.

Converting Basal Insulin Patients to Insulin Icodec

, hosts Diana Isaacs, PharmD, and Natalie Bellini, DNP, walked through the practical mechanics of switching patients from existing basal insulin regimens to icodec, the first once-weekly basal insulin approved for type 2 diabetes.

Watch the full episode discussing the commercial availability of Awiqli

The conversion begins with the patient's current total daily basal dose. Rather than simply multiplying by 7 to approximate a weekly equivalent, the initial dose calls for roughly 50% more, reached by multiplying the daily dose by 10.5, because the longer half-life delays time to steady state and a higher starting dose helps patients reach it faster. A patient taking 10 units of daily basal insulin would calculate to approximately 105 units, rounded to the nearest available increment of 100 or 110 units, before returning to a maintenance dose of 7 times the original daily amount, or 70 units weekly, for subsequent doses.

Titration will also depart from familiar basal insulin algorithms. Rather than adjusting every 3-4 days, once-weekly dosing limits adjustment frequency to ≤once per week, with clinicians reviewing 2-4 weeks of fasting and premeal glucose data before making changes, typically in 10% to 20% increments.

Hospital admission poses a separate practical question the hosts addressed directly. Because the average inpatient stay runs <3 days, well short of the weekly dosing interval, clinicians may often leave the icodec regimen untouched during a hospitalization and manage glucose with correction-dose insulin as needed, checking the timing of the patient's last dose. Isaacs and Bellini suggested inpatient glycemic control could ultimately prove more stable under a properly dosed weekly basal regimen, since it is not intended to cover meals or drive overnight drops the way rapid-acting or poorly matched basal doses can.

Patient education needs will differ by starting point. Insulin-naive patients are unlikely to be affected by the larger unit numbers involved, while patients transitioning from daily doses of 10 to 20 units to weekly doses of 70 units or more will need more deliberate counseling to avoid confusion or dosing errors.

Collectively, the hosts framed once-weekly dosing as a meaningful reduction in treatment burden, particularly for patients with caregiver support needs or a history of suboptimal adherence to daily injections, with anticipated gains in patient satisfaction expected to outweigh the learning curve required of both patients and prescribers.

Editors’ Note: Isaacs reports disclosures with Dexcom, Abbott, Lilly, Novo Nordisk, Medtronic, Insulet, and others. Bellini reports disclosures with Abbott Diabetes Care, MannKind, Povention Bio, and others.

Novo Nordisk. Novo Nordisk's Awiqli, the first once-weekly basal insulin for adults with type 2 diabetes, now available in the US. 

. August 11, 2026. Accessed August 12, 2026. 

https://www.prnewswire.com/news-releases/novo-nordisks-awiqli-the-first-once-weekly-basal-insulin-for-adults-with-type-2-diabetes-now-available-in-the-us-302847645.html

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In this segment from the latest episode of Diabetes Dialogue, Diana Isaacs, PharmD, and Natalie Bellini, DNP, discuss switching patients from basal insulin to Awiqli.

Once-weekly basal insulin is reshaping the treatment landscape for 

, offering an alternative to the daily injection burden long associated with insulin therapy. Reducing dosing frequency from seven injections a week to one carries implications for adherence, caregiver-assisted administration, and treatment satisfaction.

Insulin Icodec Dosing Strategies for Type 2 Diabetes

, hosts Diana Isaacs, PharmD, and Natalie Bellini, DNP, discussed practical strategies for initiating and titrating insulin icodec (Awiqli), now available at US pharmacies following its Food and Drug Administration approval for adults with type 2 diabetes. The conversation centered on dosing mechanics for insulin-naive patients and those switching from daily basal insulin, along with considerations for off-label use in type 1 diabetes.

For insulin-naive patients, initiation begins with a fixed dose of 70 units once weekly, titrated according to fasting glucose readings. A fasting glucose above 130 mg/dL prompts a 20-unit increase, readings between 80 and 130 mg/dL maintain the current dose, and readings below 80 mg/dL trigger a 20-unit reduction. Because dosing adjustments occur in 10-unit increments, a 20-unit change corresponds to roughly a 2 to 3-unit daily equivalent, a smaller shift than the raw numbers suggest.

Patients transitioning from a daily basal insulin require a different calculation. The initial weekly dose is derived by multiplying the current daily dose by 10.5, a strategy intended to reach steady state faster given icodec's roughly 7-day half-life. Subsequent maintenance doses are calculated by multiplying the original daily dose by seven, with titration resuming once steady state is achieved.

Insulin icodec is formulated as a U-700 concentration to limit injection volume, though it is dispensed only in a prefilled pen, minimizing dosing-error concerns tied to concentrated insulins. The agent has not received FDA approval for type 1 diabetes, following advisory committee concerns about elevated hypoglycemia rates among patients with type 1 diabetes; additional trials, including a site at Cleveland Clinic, remain ongoing.

Collectively, these dosing considerations underscore a learning curve clinicians will need to navigate as once-weekly basal insulin enters routine practice. Beyond glycemic outcomes, insulin icodec's convenience profile may prove especially valuable for older adults and patients reliant on caregiver-administered insulin, positioning it as a meaningful addition to the basal insulin armamentarium for type 2 diabetes.

In this segment from the latest episode of Diabetes Dialogue, Diana Isaacs, PharmD, and Natalie Bellini, DNP, discuss the commercial release of insulin icodec.

Continuous ketone monitoring (CKM) is emerging as a companion to continuous glucose monitoring (CGM), offering clinicians real-time insight into a complication long feared with sodium-glucose cotransporter 2 (SGLT2) inhibitor therapy: euglycemic diabetic ketoacidosis (DKA). The technology could reshape how the drug class is used in 

, where kidney-protective benefits have been weighed against ketoacidosis risk.

Continuous Ketone Monitoring May Guide SGLT2i Use in T1D

, hosts Diana Isaacs, PharmD, and Natalie Bellini, DNP, discussed early clinical experience with CKM technology, drawing on patient cases presented at an interactive Medscape education program the month prior.

Watch the full episode, featuring tech, screening, and care updates from ADCES 2026,

One case involved a patient with new-onset T1D, believed to be latent autoimmune diabetes in adults, who was managed on an SGLT2 inhibitor without insulin. Ketone testing showed moderate elevation, prompting discussion of when to initiate insulin or discontinue the SGLT2 inhibitor rather than waiting for symptoms to emerge. The case illustrated the diagnostic gap CKM is designed to close, since intermittent point-of-care ketone checks can miss the gradual rise associated with euglycemic DKA.

Clinicians are increasingly interested in extending SGLT2 inhibitor therapy, even at reduced doses, to patients with T1D for its cardiorenal protective effects, particularly in those who cannot tolerate metformin or a GLP-1 receptor agonist. The barrier remains the elevated euglycemic DKA risk unique to T1D. Continuous ketone data could allow clinicians to identify early metabolic drift and intervene before ketoacidosis develops, potentially expanding safe access to the drug class.

A second case centered on a pregnant patient carrying twins and using a connected insulin pen, where ketone monitoring supported decisions around nutritional adequacy and DKA prevention during a period of heightened metabolic risk. The discussion underscored how CKM may extend beyond T1D management to support other high-risk populations.

Both speakers acknowledged clinicians have limited experience interpreting continuous, rather than intermittent, ketone data, and said real-world device use will help define appropriate thresholds and interventions. As CKM systems reach wider clinical availability, the technology is positioned to refine risk stratification for SGLT2 inhibitor therapy in T1D and other high-risk metabolic states.

Fernando K, Akturk H. Present and Future of Continuous Ketone Monitoring: Risky or Rewarding? 

. July 10, 2026. Accessed August 12, 2026. 

https://www.medscape.com/viewarticle/present-and-future-continuous-ketone-monitoring-risky-or-2026a1000mym

In this segment from the latest episode of Diabetes Dialogue, Diana Isaacs, PharmD, and Natalie Bellini, DNP, discuss the promise of continuous ketone monitoring in T1D.

Simplified insulin delivery devices are drawing renewed clinical interest as an alternative to increasingly complex automated insulin delivery (AID) systems, offering patients injection-free mealtime and basal dosing without the programming burden of a full pump.

New Patch Pump Options Highlighted at ADCES 2026

, hosts Diana Isaacs, PharmD, and Natalie Bellini, DNP, discussed new patch pump technology showcased at the 2026 conference of the Association of Diabetes Care & Education Specialists (ADCES). The discussion centered on emerging devices from Modular Medical and CeQur.

Modular Medical's Pivot pump is a tubeless patch, worn for ≤3 days, holding ≤300 units of insulin. Each button press delivers a fixed 2-unit bolus, without carbohydrate counting or a bolus calculator. Unlike single fixed-rate devices such as V-Go, Pivot allows clinicians to program 2 distinct basal rates, adding flexibility while keeping the interface simple.

CeQur's Simplicity patch, previously limited to 3-4-day wear and 2-unit dosing, has moved toward an extended 7-day wear time with capacity ≤240 units and a new 1-unit dosing option for finer titration. Because Simplicity delivers mealtime insulin only, it still requires a separate long-acting basal insulin, positioning it as a potential companion to once-weekly basal insulins and incretin therapies as those agents reach the market. Combining these once-weekly options with Simplicity could let patients consolidate several therapies into a single day of dosing each week.

Modular Medical has indicated plans to pursue full automation for Pivot by partnering with a sensor and dosing algorithm, a step expected to require additional development, clinical study, and regulatory review over approximately 2 years. In the meantime, both devices reflect a countervailing trend in diabetes technology, prioritizing simplified, lower-burden insulin delivery for patients on multiple daily injections not seeking full automation.

Modular Medical. Modular Medical Announces Launch of Pivot Insulin Delivery System Across Five Key U.S. Markets Beginning October 2026. 

. August 3, 2026. Accessed August 11, 2026. 

https://www.biospace.com/press-releases/modular-medical-announces-launch-of-pivot-insulin-delivery-system-across-five-key-u-s-markets-beginning-october-2026

CeQur Simplicity. Extended 7-Day Wear and 1-Unit Dosing Clearances, and Two ADA Posters Signal a New Standard for Mealtime Insulin Management. June 4, 2026. Accessed August 11, 2026. 

https://myceqursimplicity.com/cequr-announces-exciting-advancements-2-recent-fda-clearances-and-new-clinical-evidence-to-be-presented-at-ada/

In this segment from the latest episode of Diabetes Dialogue, Diana Isaacs, PharmD, and Natalie Bellini, DNP, discuss new insulin pump technology presented at ADCES 2026.

Natalie Bellini, DNP, FNP, BC-ADM, CDCES

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