This Physician’s Weekly feature on initiating insulin and strategies to overcome patient fears was completed in cooperation with the experts at the American Diabetes Association.

Many patients with type 2 diabetes eventually require insulin therapy and benefit from it. Timely initiation of insulin is critical to managing diabetes and helping patients avoid disease-related complications. “Insulin is an effective treatment for diabetes, but patients and physicians alike often consider this therapy a last resort. This can lead to long delays in patients starting insulin, which in turn lead to longer periods of elevated blood sugars that place these individuals at higher risk for complications,” says Jeremy Pettus, MD. “The reasons why patients are hesitant to take insulin are multifactorial. Providers need to understand the barriers to insulin initiation and reduce any negative perceptions that patients may have about taking this important medication.”

Considering Patient Barriers

Many patients have misconceptions on what it means to be prescribed insulin, according to Dr. Pettus. Some patients see insulin as potentially leading to more health problems down the road. Others perceive it as a punishment if they fail to do what is necessary to properly manage their diabetes. Clinicians should get an understanding of patients’ views on insulin before they initiate it. “We should inform patients about the progressive nature of the disease that commonly results in requiring insulin and objectively explain to them why insulin is required,” Dr. Pettus says. “These conversations should happen early after a diabetes diagnosis and be framed in a way that leaves open the possibility that insulin may be necessary later in the course of the disease. In this way, insulin therapy is not a punishment, but a potential future therapeutic option.”


Taking time to identify the reasons behind patient concerns can help physicians develop a strategy to initiating insulin. Determining the level of concern and asking open-ended questions about patient perceptions on insulin can help (Table 1). “We need to listen to patient responses to help us better understand why patients are apprehensive and then address the issues early,” adds Dr. Pettus.

Patient Education Matters

Several strategies have been effective when addressing patient barriers to starting insulin. “Throughout the course of care, it’s important to educate patients about their treatment options and the medications they’re taking,” says Dr. Pettus. “They should also understand that insulin will be required when non-insulin treatment options are no longer effective.” He recommends informing patients early that insulin may be needed to prepare them well in advance of this potential need.

Stress the Positives

Patients with diabetes should be informed that insulin is a hormone that is normally made by their own pancreas. Framing insulin therapy in this way as a natural therapy can often help reduce patient apprehension. Offering education about how insulin initiation can be a good thing may ease patient apprehension, Dr. Pettus says. “We should stress the positive attributes that insulin can provide for patients. Insulin can help them continue to enjoy flexibility in their lives, perhaps with more energy to do activities they like doing”

To address fears about painful injections, Dr. Pettus suggests that clinicians focus on telling patients about the advances that have been made with insulin needles. “The needles we use for insulin injections today are smaller and thinner than ever before,” he says (Table 2). “Taking some extra time to show patients that injections are painless can go a long way to alleviating fears.” Some reports suggest that most patients find insulin injections to be less painful than testing their blood sugar.

Some patients with diabetes have heard about negative experiences with insulin through relatives or friends. As a result, they may believe that insulin actually causes complications or death. “We may need to do more than simply present the facts on insulin to overcome patients’ fears,” Dr. Pettus says. He recommends that clinicians think about providing anecdotal information from their own experiences with managing patients who were fearful of starting insulin.

Involve DSMEs

When initiating insulin, diabetes self-management educators (DSMEs) can be a great asset, especially in busy office settings. “DSMEs can help with both initiating and titrating insulin,” says Dr. Pettus. “They can offer education about insulin and support efforts to ensure that patients continue using insulin as directed. DSMEs can also support and reinforce other important self-management strategies to diabetes care, particularly during early phases of the disease. Ultimately, the way to overcome fears of starting insulin will be to establish a proactive, collaborative relationship with patients. Taking time to teach patients about insulin and address their concerns early and often—and throughout treatment—will ensure that these messages are supportive and specific for each person with diabetes.”


American Diabetes Association. Standards of Medical Care in Diabetes—2013. Diabetes Care. 2013;36:S1-S110.

Funnell MM. Overcoming barriers to the initiation of insulin therapy. Clin Diabetes. 2007;25:36-38. Available at:

Peyrot M, Rubin RR, Lauritzen T, et al, the International DAWN Advisory Panel. Resistance to insulin therapy among patients and provides: results of the cross-national Diabetes Attitudes, Wishes and Needs study. Diabetes Care. 2005;28:2673-2679.

Nathan DM, Buse JB, Davidson MB, et al. Medical management of hyperglycemia in type 2 diabetes: a consensus algorithm for the initiation and adjustment of therapy: a consensus statement of the American Diabetes Association and the European Association for the Study of Diabetes. Diabetes Care. 2009;32:193-203.

Kabadi UM. Starting insulin in type 2 diabetes: overcoming barriers to insulin therapy. Int J Diabetes Dev Ctries. 2008;28:65-68.

Hunt LM, Valenzuela MA, Pugh JA. NIDDM patients’ fears and hopes about insulin therapy: the basis of patient reluctance. Diabetes Care. 1997;20:292-298.