<aside> 💉 Failure of oral medications is common in long-standing type 2 diabetes mellitus due to progressive loss of pancreatic beta cell function.  Patients should be counseled that because of the natural history of the condition, the need for supplemental insulin is common and does not represent a personal failure.

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• Failure of oral medications is common in long-standing type 2 diabetes mellitus due to progressive loss of pancreatic beta cell function.  Basal insulin therapy is often necessary, especially when multiple agents have failed or when a patient has a hemoglobin A1c >9%.
• It is common for patients to have reservations about initiating insulin due to treatment complexity, risk of hypoglycemia, or injection pain.  However, this patient is expressing concern that the failure of oral agents represents a personal inadequacy; in other words, he thinks that his diabetes is uncontrolled because he has failed to follow lifestyle recommendations (ie, diet).
• In counseling patients with treatment failure, especially those who have overpersonalized their medical condition, it is appropriate to review the natural history of the condition.  In this case, the clinician should explain that type 2 diabetes is a progressive disorder and that escalating treatment regimens are often the norm.  Lifestyle factors (eg, diet, weight loss) should not be neglected but should be discussed in a compassionate, nonjudgmental way, and self-blame should not be encouraged.