What’s the best diabetes drug? New study says "any."

As I’ve discussed before on this blog, whenever someone is pre-diabetic, the first “drug” is really a change in their lifestyle. Many people can slow the progression of diabetes, and sometimes even reverse it, through significant changes to their diet and by adopting a regular exercise routine. (And if you don’t get enough sleep, work on that, too.)

After that, the first drug is always Metformin. The American Diabetes Association recommends it as the first treatment for good reason: it’s been around for a long time, it is very well recognized as safe, and the side effects usually aren’t serious.

But what if Metformin doesn’t work well enough? Many patients start wondering about direct insulin injections, but insulin is a very powerful drug, and it is prone to causing hypoglycemia. The problem for patients, however, is that, after Metformin, there is a dizzying array of possibilities.

Thankfully, a new study in the Journal of the American Medical Association makes clear that there really isn’t one single choice. No one type of drug seems to be better to add to Metformin that another type. As they concluded, “Among adults with type 2 diabetes, there were no significant differences in the associations between any of 9 available classes of glucose-lowering drugs (alone or in combination) and the risk of cardiovascular or all-cause mortality.”

So what does this mean for patients?

Personally, I think that a thiazolidinedione is the next best option, for safety reasons. They have been linked with an increased risk of bladder cancer, which sounds scary, but the increase is modest, and bladder cancer is one of the most easily detected and treated types of cancers. In comparison, the DPP-4 inhibitors and the GLP-1 receptor antagonists have been linked with an increased risk of pancreatic cancer, which is rarely caught at a treatable stage and which is usually fatal.

This all sounds extremely scary, but two points should be remembered. First, any type of cancer is rare with these drugs. Second, when we are talking about unusual and rare side effects like cancer, it makes sense to choose the option with the less risky side effect. No one would ever “choose” to have bladder cancer, but if it’s a choice between bladder cancer and pancreatic cancer, I think that’s a simple choice.

Some people might ask: what about SGLT-2 inhibitors? The problem with these drugs is that they are very new, and haven’t been out on the market long enough to know if they have their own link with cancer.