Use of Once-Weekly Insulin Icodec in the Perioperative and Inpatient Settings

Résumé

Hyperglycemia in hospitalized patients is associated with increased morbidity, mortality, and healthcare utilization, and effective glycemic management remains a central component of inpatient care. Basal insulin therapy is a cornerstone of this management strategy, traditionally relying on once-daily long-acting insulin analogs that allow for flexible titration. Insulin icodec, a once-weekly basal insulin analog, represents a significant therapeutic advance by reducing injection burden and providing stable pharmacokinetics; however, it also introduces new challenges in acute care settings.

Insulin icodec exhibits reversible albumin binding and a prolonged half-life of approximately 196 hours (~8 days). It reaches a steady state after 3–4 weekly injections and is associated with a relatively flat, sustained glucose-lowering profile. While these properties are advantageous in the outpatient setting, they limit the ability to rapidly titrate insulin dosing in response to acute illness, fasting, or surgical stress. This reduced flexibility raises concerns regarding its safety and practicality in hospitalized and perioperative patients, where insulin requirements may change abruptly. Diabetes Canada inpatient guidance emphasizes the importance of individualized insulin regimens and the ability to adjust therapy dynamically in response to changing clinical status, principles that may be more difficult to implement with once-weekly insulin formulations. This review focuses on adults with type 2 diabetes, in whom most clinical experience with insulin icodec has been accumulated.