Daily basal insulin could be about to become weekly
NICE has backed a treatment for type 2s that could replace a daily basal injection with one injection every 7 days. The new insulin is called efsitora alfa, branded as Onswik and developed by Eli Lilly. NICE calculates that someone currently taking one basal injection every day could potentially go from 365 of those injections a year to just 52, an 85% reduction.
Unlike much of today's diabetes innovation, Onswik doesn't promise more data, more measurements or even substantially better glucose results. Instead, it is offering something rather simpler: less diabetes to do.
What is once-weekly insulin?
Efsitora is an ultra-long-acting basal insulin, designed to provide the background insulin that is usually injected every day. It has been developed to remain active across an entire week, allowing that basal dose to be given once every 7 days.
This only applies to people with type 2 diabetes who need insulin, and it doesn't remove rapid-acting injections for those who also take insulin around meals. But for someone whose insulin treatment consists of one daily basal injection, the change could be very straightforward.
Is weekly insulin as effective as daily insulin?
Clinical trials of efsitora don't show a dramatic improvement in glucose control, but instead suggest people may be able to inject their basal insulin much less frequently without sacrificing the glucose control achieved with daily treatment.
In the QWINT-1 phase 3 trial, 795 adults with type 2 diabetes who had not previously used insulin received either once-weekly efsitora or once-daily insulin glargine. After 52 weeks, HbA1c had fallen from 8.20% to 7.05% with efsitora and from 8.28% to 7.08% with daily glargine.
The difference between the two was extremely small, with weekly efsitora found to be non-inferior to daily insulin. Other studies in Lilly's QWINT programme have reached similar conclusions when efsitora has been compared with established daily basal insulins.
So this isn't really about achieving a lower HbA1c. For some users, it is about potentially achieving a similar result with 313 fewer basal injections every year
Who could benefit most?
For some people, changing a daily injection to a weekly one may simply be more convenient. For others, it could make a much bigger difference.
NICE has highlighted people who need assistance to administer insulin, including some people with sight loss, learning disabilities or physical difficulties. Where a family member, carer or healthcare professional provides that help, reducing 7 injections to one each week could also substantially reduce how often assistance is required.
There is a physical benefit too. Fewer injections mean fewer needles and fewer times the skin has to be punctured. Repeated insulin injections can cause bruising, irritation and fatty lumps under the skin known as lipohypertrophy, particularly when the same areas are used repeatedly. These lumps can also affect how consistently insulin is absorbed, which is why people using insulin are advised to rotate their injection sites.
Reducing daily basal injections to once a week would not remove the risk of injection-site problems altogether, particularly for people who also use rapid-acting insulin. But for someone using basal insulin alone, it could mean more than 300 fewer injections into the skin every year.
There may also be benefits for people who struggle to remember a daily basal dose. A weekly treatment still has to be taken correctly and on schedule, but remembering an injection 52 times a year is a very different routine from remembering it 365 times.
Could weekly insulin make starting insulin easier?
Starting insulin can represent a significant change for someone with type 2 diabetes. It introduces injections, equipment and another treatment that has to become part of everyday life. A weekly basal insulin changes that proposition considerably.
Instead of telling someone they now need to inject every day, DSNs and other healthcare professionals could potentially offer basal insulin that only needs to be administered once a week. We won't know until it is being used more widely whether that makes people more willing to start insulin when it is clinically needed, but it potentially removes one of the practical barriers.
An insulin designed to work for 7 days requires patients and healthcare professionals to think differently about starting doses, adjustments and what happens if a dose is missed or accidentally repeated. That makes clear dosing instructions particularly important.
There are questions about flexibility too. Clinical trials follow defined dosing and adjustment protocols that don't always reflect the way insulin is managed in everyday life, so real-world experience will become particularly important.
The main QWINT trials were also funded by Eli Lilly, which has developed efsitora, with a number of researchers employed by the company. That is normal in late-stage pharmaceutical development, but independent research and post-launch evidence will help show how well the benefits seen in trials translate into ordinary diabetes care.
Where do CGMs fit into this?
CGM development is moving towards more information, with glucose readings every few minutes, trend arrows, alarms, time in range, predictions and increasingly sophisticated algorithms. Once-weekly insulin is moving in almost the opposite direction, towards doing something less frequently.
For people already using CGM, however, the two could complement each other. CGM could show how glucose patterns change across the 7-day dosing cycle, helping individuals and healthcare professionals understand how the weekly insulin is performing and whether the dose may need adjusting.
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No. NICE's appraisal of insulin efsitora alfa for adults with type 2 diabetes is still formally in development, with its current expected publication date listed as 22 October 2026.
Onswik also still needs UK marketing authorisation from the MHRA before it can be prescribed to NHS or private patients.
So the NICE recommendation is an important step towards once-weekly insulin becoming available, rather than confirmation that type 2s can ask their DSN or GP for Onswik yet.
Is once-weekly insulin really a big change?
For someone who already takes a daily basal injection without much difficulty, moving to once a week may feel like little more than added convenience. For somebody who struggles with injections, forgets doses or needs another person to administer their insulin, removing more than 300 injections from the year could look considerably more significant.
Diabetes already involves thousands of repeated actions: injections, tablets, sensor changes, finger-pricks, carb calculations, prescriptions, appointments, alarms and decisions. Much of diabetes technology is competing to add more information or more capability to that list.
Efsitora could give T2Ds something less to do.
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