Insulin Icodec in India: A Narrative Review of the First Once-Weekly Basal Insulin

Insulin icodec is the first once-weekly basal insulin. Three amino acid substitutions and a fatty acid side chain allow it to bind reversibly to albumin, giving a half-life of 196 hours, so one injection covers a week. Across the six ONWARDS phase 3a trials, icodec was non-inferior to daily basal insulins on HbA1c reduction and superior in ONWARDS 1, 2, 3 and 5. Pooled analysis, however, shows this advantage comes almost entirely from comparisons against degludec; against glargine U100 - the insulin most Indian patients use - there is no significant difference. Hypoglycemia stayed below one episode per patient-year in type 2 diabetes but was clearly more common with icodec in type 1 diabetes. Among 217 Indian participants, HbA1c control was comparable, but with no advantage in reaching target and a concerning loss of fasting glucose control in type 1 diabetes by one year. Cleared by the US FDA for type 2 diabetes in March 2026 and launched in India on 9 July 2026, icodec’s value rests on fewer injections and lower cost, not better glycemic control.