MannKind Corp. (NASDAQ: MNKD) remains one of the most controversial bio-health stocks of them all. Its stock was under pressure on Wednesday on news of a key analyst downgrade. The move may have been altered a bit due to MannKind being one of the most shorted stocks on Wall Street. What is interesting about this downgrade is that it nearly echoes some of the concerns that already have been brought up in the weeks and months prior to this call.

RBC Capital Markets’ Adnan Butt downgraded MannKind on Wednesday to Underperform from a Market Perform rating. Note that Butt’s price target was a mere $1.00 — after having been at $9.00 in prior calls.

Also note that the analyst had trimmed his target to $9.00 from $10.00 back in August. The newer call cited that a physician survey was signaling sluggish growth for Afrezza, MannKind’s inhalable insulin. Apparently, doctors are seeing Afrezza’s out-of-pocket costs for patients as higher than other insulin products.

RBC’s call further said something that may be more of a concern than the physician interest, and that is that patient interest remains low. Does the idea of an inhalable insulin sound worse than an injection? Another negative force was that Afrezza prescriptions are getting lost or unfilled due to payer hurdles.

What is amazing about the scope of this downgrade from RBC, and all the negativity around MannKind, is that the controversy around this stock just seems to go on and on. Afrezza is an inhalable form of insulin, and some diabetics just hate giving themselves insulin injections. Afrezza also still has a very limited time on the market, and it was generally expected that doctors might be slow to change their standard of care after many years of consistent treatment for diabetes.

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Keep in mind that MannKind is expected to report earnings in just five days. This call would certainly lower the bar for what is expected in sales, but it would also be at a time when MannKind is effectively in a quiet period around earnings.

Thomson Reuters is calling for revenue of only $180,000 in the September quarter, the portion that MannKind gets from partner Sanofi S.A. (NYSE: SNY). Sales of less than $500,000 in 2015 are also expected by analysts to rise to over $9.7 million.

The last thing to be addressed outside of this analyst call is that MannKind’s short interest remains through the roof. Some 124 million shares were short as of October 15, 2015. That is down slightly from the peak short interest, but there has been no single short interest report with under 100 million shares since mid-April. Its days to cover now is roughly 29.

The reality is that MannKind remains about as controversial of a stock as one can find. It comes with great promise, which has so far been elusive.

MannKind shares were last seen down about 7% to $3.01 in early afternoon trading Wednesday. It has traded 5.7 million shares, versus a 5 million share average per day. MannKind’s 52-week range is $2.88 to $7.88, and its market cap is $1.24 billion.

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