Once-Weekly Insulin Icodec Matches Daily Basal Insulin in Indian Subgroup of ONWARDS Trials

A new analysis of Indian participants from the global ONWARDS Phase 3a trials indicates that once-weekly insulin icodec provides glycemic control comparable to daily basal insulin in both type 1 and type 2 diabetes. The findings offer early support for the clinical viability of icodec, attempting to address the significant challenges posed by injection burden and adherence.

The analysis pooled data from three randomized trials: ONWARDS 1, which studied insulin-naïve adults with type 2 diabetes; ONWARDS 4, which included patients with type 2 diabetes already on basal-bolus therapy; and ONWARDS 6, which focused on people with type 1 diabetes. Across these trials, a total of 217 participants were randomized to receive either once-weekly icodec or a once-daily basal insulin—glargine U100 in ONWARDS 1 and 4, and insulin degludec in ONWARDS 6.

At 26 or 52 weeks, depending on the trial, reductions in HbA₁c were nearly identical between icodec and comparator arms. Estimated treatment differences ranged from −0.04% to +0.08%, establishing noninferiority of icodec. Continuous glucose monitoring also showed comparable time in range (70–180 mg/dL), reinforcing the primary glycemic findings.

Hypoglycemia outcomes favored icodec in type 2 diabetes. Both ONWARDS 1 and 4 showed numerically lower rates of level 2 or 3 hypoglycemia in the icodec group compared to those receiving glargine. In ONWARDS 6, however, the rate of hypoglycemia was somewhat higher with icodec than with degludec—a trend seen in the broader global dataset as well.

No new safety concerns were observed, and adverse event profiles were similar across treatment arms. Notably, Indian participants tended to be younger, leaner, and have shorter diabetes duration but higher baseline HbA₁c levels than their global counterparts. Despite these demographic and clinical differences, icodec’s efficacy appeared consistent.

The authors note that while these findings are promising, the Indian subgroup was not powered for definitive conclusions—particularly in the type 1 diabetes cohort, which had a small sample size. The open-label design also leaves room for potential bias in insulin titration.

Still, the data suggest that icodec may offer a convenient and effective alternative to daily basal insulin for Indian patients with diabetes, potentially improving adherence in settings where injection fatigue is common. Larger studies and real-world evidence will be necessary to validate these early signals and assess whether less frequent dosing translates into better long-term outcomes.