Once-Weekly Insulin Efsitora (Onswik)
Now people with type 2 can choose from 2 different Once Weekly basal insulins!
On September 24, 2026, the FDA approved insulin efsitora (Onswik™) for adults with type 2 diabetes. For diabetes healthcare professionals, this adds another once-weekly option for matching treatment to a person’s needs, preferences, and daily routine.
What Is Insulin Efsitora?
Efsitora is Lilly’s once-weekly basal insulin approved for people living with type 2 diabetes. Weekly administration reduces the number of basal injections from approximately 365 to 52 per year. Like the other weekly insulin, icodec, it does not eliminate mealtime injections for people who need prandial insulin.
At the time of the approval announcement, Lilly anticipated U.S. availability in the coming months.
Pharmacology Spotlight: What Makes Efsitora Different
Efsitora is an insulin fusion protein incorporating an immunoglobulin Fc region. This molecular design prolongs its time in circulation; it does not use icodec’s albumin-binding mechanism. The two insulins have different pharmacology, dosing and storage properties and require their own education and prescribing instructions (see comparative table below).
A Long Half-Life Means We Need to Think in Weeks, Not Days
Efsitora has an exceptionally long half-life of approximately 17 days, compared with about 7 days for icodec. Across the four QWINT studies, efsitora provided a relatively consistent glucose-lowering effect throughout the weekly dosing interval once steady state was achieved. Because of its long duration of action, however, it takes time to fully build up in the body, with clinical steady state generally reached after about four to six weeks.
What does this mean for us in clinical practice? Patience is important. In the outpatient setting, we need to look at fasting glucose and CGM trends over time rather than reacting too quickly to a few days of glucose data. Dose adjustments should be thoughtful and gradual, recognizing that the effects of previous weekly doses are still contributing to glucose management.
That long duration of action is also important when someone is hospitalized or preparing for a procedure. Medication reconciliation should clearly document which weekly insulin the person is taking, the dose and pen concentration, and when the last injection was given. Knowing how much weekly insulin may still be active can help the acute care team safely plan subsequent insulin therapy and reduce the risk of unintended insulin overlap and hypoglycemia.
Table Comparing the 2 weekly insulins
Safety Considerations: What Should We Watch For?
1. Hypoglycemia Risk and Considerations
As with all basal insulins, there is a comparable risk of hypoglycemia. When working with individuals starting this new insulin, using a CGM to monitor ongoing glucose levels will help with needed adjustments over time. Of course, having a back-up glucose monitor is also very important along with reinforcing the signs of hypoglycemia and action to take.
Check in with individuals to help them figure out a system to record their weekly injection day. Discuss recognition and treatment of low glucose, access to rescue treatment, and when to contact the diabetes team. Written or electronic calendar reminders can be especially helpful when someone uses more than one weekly injectable medicine.
2. Dosing & Missed Doses – See Package Insert for Dosing Info
According to the package insert, for insulin-naïve adults, fixed titration starts at 100 units weekly; flexible titration is based on current insulin dose, glucose goals and other factors. See Package Insert for Dosing Info.
Missed dose: give within four days, then keep the schedule. After four days, skip or administer and restart weekly dosing seven days later. Increase monitoring. Renal impairment calls for individualized monitoring and dosing, not automatic eGFR percentage reductions.
3. Pen Concentration and Storage
U-500 pens contain 1,500 units, deliver 5-unit increments, and allow a maximum of 400 units per injection. U-1,000 pens contain 3,000 units, deliver 10-unit increments, and allow 800 maximum units per injection.
Refrigerate at 36–46°F; cumulative room-temperature exposure up to 86°F must not exceed 14 days. Discard 16 weeks after first use. Do not freeze.
Clinical Efficacy: What Does the Evidence Show?
Across the four QWINT registration trials involving adults with type 2 diabetes, more than 3,400 participants were enrolled. Efsitora demonstrated noninferior A1C reductions compared with once-daily insulin glargine U-100 or insulin degludec U-100, supporting once-weekly efsitora as an effective option for glucose management.
Of course, comparable glucose lowering doesn’t mean once-weekly insulin will be the best choice for everyone. As diabetes healthcare professionals, our role is to explore the potential benefits and challenges of weekly insulin with each person. Some may welcome fewer injections and a simpler routine, while others may prefer the familiarity and flexibility of daily basal insulin. The best insulin is the one that safely meets the person’s clinical needs, preferences, and lifestyle.
Final Thoughts
Choosing treatment together
Weekly basal insulin may appeal to people who find daily injections burdensome, including those hesitant to begin insulin. The discussion should also explore comfort with a weekly schedule, access to monitoring, caregiver support when needed, and coverage and cost. Reduced injection frequency may ease treatment burden, but real-world persistence and outcomes will need continued evaluation.
A useful opening question is, “What feels hardest about your current insulin routine?” The answer can guide whether weekly basal insulin addresses the person’s actual barrier. As diabetes healthcare professionals, our role is to combine current evidence with practical education and curiosity, helping each person choose a plan they can use safely and confidently.
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