The 2026 Dyslipidemia Guideline has comparative recommendations, encouraging a dietary pattern rich in fruits, vegetables, nuts, legumes, whole grains, and fiber, while reducing saturated fat and replacing it with mono and polyunsaturated fats. It noted that dietary patterns that reduce saturated fat and increase unsaturated fat was more effective than restricting dietary cholesterol.² 

The guideline reinforces the cardiovascular benefits of the Mediterranean, DASH, and vegetarian eating patterns and highlights the under-recognized Portfolio dietary pattern, which was shown to lower LDL by approximately 26 mg/dL. This dietary pattern emphasizes inclusion of 50 grams of plant-based protein per day, 45 grams of nuts, at least 10 grams of viscous fiber, and 2 grams of plant sterols per day.³ 

Additional guidelines are given for hypertriglyceridemia depending upon level of elevation². If triglycerides (TGs) are 150-499, added sugars are limited to 6% of calories, total fat is 30-35%, and alcohol is to be avoided. If TGs are 500-999, added sugars are limited to <5% of calories, total fat to 20-25%, and it is recommended to abstain completely from alcohol. If TGs are over 1000 mg/dl, added sugars are eliminated, total fat is limited to 10-19%, and again, alcohol abstinence is recommended. 

For all groups, 150 minutes of activity is recommended, and 5-10% weight loss is considered for individuals who may benefit. Consideration of the amount, type, and quality of carbohydrates shows efficacy in lowering TGs. In addition to LDL and TG lowering, dietary patterns aim to improve overall metabolic health, including weight reduction, reduced inflammation, and improved blood pressure and glucose control.²

1. Hypoglycemia Risk and Considerations

• The effect of insulin icodec is highest at Days 2-4 of the weekly dosing cycle, increasing the risk of hypoglycemia on these days. See Awiqli Monograph
• There are still concerns about increased hypoglycemia risk for people with type 1 diabetes. For that reason, the FDA has not approved insulin icodec for use in people with type 1 diabetes at this time.
• For those with type 2 diabetes, the risk of hypoglycemia is comparable to those on daily bolus injections.
• Diabetes healthcare professionals are encouraged to review the signs of hypoglycemia and importance of quickly consuming carbs to raise glucose levels.
• Making sure individuals on icodec have a meter or CGM to monitor glucose response is imperative for safety, especially when making dose adjustments.
• If someone becomes acutely ill and is not eating or needs to fast for a procedure, there is less flexibility to immediately adjust the dose because of the ultra long insulin half-life.
• Health care teams will need to have protocols for how to treat patients admitted to hospital on weekly insulin to ensure they are not giving additional basal insulin when the weekly insulin is still in their system. 

2. Dosing & Titration Complexity – See Package Insert for Dosing Info

• When initiating insulin icodec, dosing is typically based on the person’s current total daily basal insulin dose, with the goal of maintaining equivalent weekly insulin exposure.
• A practical approach is to multiply the existing daily basal dose by 7 to estimate the initial once-weekly dose, followed by careful titration based on fasting glucose trends.
  

  See Package Insert for Dosing Info

• For individuals who are insulin-naïve, a standard starting dose (e.g., 70 units once weekly in clinical trials) may be used, with adjustments made weekly or every few weeks depending on glycemic response.
• Because of icodec’s long half-life and delayed steady state, dose changes take longer to fully manifest, so clinicians should avoid making rapid or frequent adjustments.
• As always, individualization is key—consider factors such as hypoglycemia risk, renal function, and patient ability to monitor glucose when determining and adjusting the dose.

3. Dose Adjustment in Altered Kidney Function   – See Package Insert for Dosing Info

The following recommendations based on kidney function are suggested.

• eGFR of 50 or greater – no dosage adjustment needed.
• eGFR of 10-50 – administer 75% of the usual starting dose.
• eGFR less than 10 – administer 50% of usual dose.

4. Missed Doses   – See Package Insert for Dosing Info

The following recommendations for missed doses are suggested:

• If 3 or fewer days until next regularly scheduled dose: Administer missed dose as soon as possible. Reset weekly dosing schedule to start one week later.
• If 4 or more days until next regularly scheduled dose: Administer missed dose as soon as possible. Continue current weekly dosing schedule.