For decades, basal insulin meant a daily injection. That changed in 2026, when two once-weekly basal insulins reached the U.S. market within months of each other: Novo Nordisk's Awiqli (insulin icodec), approved in March 2026, and Eli Lilly's Onswik (insulin efsitora alfa), approved September 24, 2026. Both aim to reduce injection burden for adults with type 2 diabetes, but they come from different companies with different trial programs and, at least on paper, some different trial results.
Shared Mechanism
Both drugs are basal insulin analogs engineered for an extended half-life that allows once-weekly dosing instead of the daily injections required by older basal insulins like glargine (Lantus) and degludec (Tresiba). Both are intended to provide steady, background insulin coverage, not to replace mealtime (bolus) insulin for patients who need it, and neither is approved for type 1 diabetes.
Trial Programs
Awiqli was studied in Novo Nordisk's ONWARDS trial program, which compared it against daily insulins including glargine and degludec across multiple studies, though its U.S. approval covers type 2 diabetes specifically. Onswik was studied in Eli Lilly's QWINT trial program, which enrolled roughly 3,400 adults with type 2 diabetes and also compared it against glargine and degludec. In Lilly's QWINT-2 trial, Onswik reduced A1C by 1.34 percentage points versus 1.26 for degludec, results the company has characterized as clinically comparable, or numerically favorable, to the standard daily comparator.
What's Actually Different
Because Awiqli and Onswik have not been tested against each other directly in a head-to-head trial, comparing their individual trial results against different comparator arms is informative but not a substitute for direct evidence. Differences in trial populations, background therapy, and comparator insulins mean that a slightly larger A1C reduction in one program's data doesn't reliably predict which drug would perform better if tested against the other directly. Practical differences that matter more immediately for patients include formulary coverage, insurance-driven cost, and how each company's injection device and dosing schedule fit into daily life.
Safety Profile
Both drugs carry the safety profile expected of any basal insulin, with hypoglycemia as the primary risk, and both require careful blood sugar monitoring during the transition from a daily insulin regimen to a weekly one, since the pharmacokinetics of a week-long insulin action differ meaningfully from a 24-hour one.
The Bottom Line
Awiqli and Onswik represent genuine competition in an insulin category that hadn't seen this kind of dosing innovation in years, but with no direct comparative trial between them, the honest answer for now is that both appear to be reasonable once-weekly options with similar mechanisms and similar, if not identical, efficacy signals from their respective trial programs.
Talk to Your Doctor
Which basal insulin is appropriate, and whether a once-weekly option is a good fit, depends on individual factors including insurance coverage, other medications, and how consistently a patient can manage a weekly versus daily injection schedule. This is a decision to make with a prescribing physician, not one based on marketing claims from either manufacturer.