Why do people with established diabetes, such as those on Fiasp (insulin aspart) and Basalog (insulin glargine), often view insulin therapy negatively?

Why People View Insulin Therapy Negatively

Insulin therapy is often perceived negatively due to psychological barriers including fear of injections, hypoglycemia concerns, perceived treatment failure, weight gain anxiety, and social stigma—despite being one of the most effective glucose-lowering treatments available. 1

Primary Psychological and Social Barriers

Fear and Misconceptions

• Fear of hypoglycemia represents the most significant barrier to insulin acceptance, with patients worrying about dangerous blood sugar drops that could occur unpredictably 1, 2
• Injection anxiety creates substantial resistance, as the subcutaneous administration method feels invasive and painful compared to oral medications 1
• Social stigma associated with visible injections leads to embarrassment and reluctance to use insulin in public settings 1

Perception of Treatment Failure

• Many patients interpret insulin initiation as evidence of personal failure in managing their diabetes, viewing it as punishment for not controlling their condition adequately 1
• The progression to insulin is often framed by providers as a threat ("if you don't improve, you'll need insulin"), which reinforces negative associations and makes the eventual transition more difficult 3

Weight Gain Concerns

• Insulin therapy is associated with weight gain of several kilograms, which conflicts with patients' desires to lose weight and contradicts other diabetes management advice 4, 2
• This weight gain occurs because insulin promotes glucose storage and reduces glycosuria, but patients perceive it as a negative side effect 4

Practical Burden and Lifestyle Impact

Treatment Complexity

• Insulin requires daily glucose monitoring with finger-stick testing, adding burden to daily routines 1
• The need for proper injection technique, site rotation, and insulin storage creates additional complexity that oral medications don't require 5
• Patients must learn to recognize and treat hypoglycemia, manage "sick days," and adjust doses based on glucose patterns 5

Loss of Flexibility

• Unlike oral medications taken once or twice daily, insulin demands precise timing and coordination with meals 1
• The requirement for consistent meal schedules and carbohydrate content reduces spontaneity in daily life 3

Provider-Related Barriers

Clinical Inertia

• Healthcare providers often delay insulin initiation due to their own concerns about patient capabilities, lack of confidence in managing insulin therapy, and perceptions of risk 2
• Providers may lack experience with insulin titration algorithms and avoid decisions they perceive as risky for their patients 2

Inadequate Education and Support

• Insufficient patient education about the progressive nature of type 2 diabetes contributes to negative perceptions 3
• Early education about expected disease progression and avoidance of insulin "threats" is critical but often neglected 3

Guideline Positioning Issues

• Recent clinical guidelines position insulin reactively and late in treatment algorithms, reinforcing the perception that insulin represents treatment failure rather than appropriate disease management 1
• This delayed positioning contributes to therapeutic inertia and patients' negative associations with insulin therapy 1

The Reality vs. Perception Gap

Actual Clinical Benefits

• Insulin is the most effective glucose-lowering agent available, particularly when HbA1c is very high (≥9.0%) 5
• Modern basal insulin analogues like insulin glargine provide consistent 24-hour coverage with significantly lower rates of nocturnal hypoglycemia compared to older NPH insulin 6
• Insulin therapy has anti-atherogenic effects on serum lipid profiles and can reduce postprandial triglyceride levels 4, 7

Manageable Risks

• When properly implemented with appropriate titration and monitoring, insulin therapy achieves HbA1c reductions of 2-3% without increased hypoglycemia risk 5
• The risk of major hypoglycemia with modern insulin regimens is not significantly different from other treatments when properly managed 7

Potential Solutions

• Once-weekly insulin formulations currently in development (insulin icodec and basal insulin BIF) may improve initial acceptance, adherence, and treatment satisfaction by reducing injection frequency 1
• Early patient education about diabetes progression and the eventual need for insulin can normalize insulin therapy and reduce negative associations 3
• Empowering patients with self-titration algorithms based on glucose monitoring improves control and gives patients a sense of agency rather than helplessness 3