3 steps to treat Diabetes

• Step 1: Fight diabetes with lifestyle changes.

Cost: Free or low cost.

If you are pre-diabetic or recently diagnosed, you may be able to dodge the expense of drug treatment with exercise and a better diet and by quitting smoking. None of this has to cost a fortune, and in any event healthier foods and, if necessary, a gym membership or other exercise program are well worth the investment. Even if you are taking medication, these lifestyle changes can help the medicine work better and longer.

• Step 2: If you need to begin taking a drug to control blood sugar, start with metformin, the most common and one of the least expensive diabetes drugs.

Cost: $36 for 100 pills (500 milligrams); usually taken twice a day. Prices may be even lower at Wal-Mart, Target and other discount pharmacies.

Metformin almost always works as a first-line drug, except for patients suffering from severe kidney disease, said Dr. Bennett. What's more, metformin generally does not cause hypoglycemia, a common and dangerous side affect of many diabetes drugs.

It also does not seem to cause weight gain, as some other diabetes drugs do, said Dr. Bennett. "The last thing you want if you've been diagnosed with diabetes is additional weight," she added.

A study published in Consumer Reports Health in February 2009 also found that older, less expensive diabetes drugs were just as effective as the new ones. Better yet, they have established safety records, while some newer diabetes drugs have been found to increase cardiovascular and other health risks.

"The expensive drugs are third- and fourth-line drugs," said Dr. Marvin Lipman, chief medical adviser for Consumer Reports Health and a practicing endocrinologist in Westchester County, N.Y. "If you don't get results with the less expensive drugs, you go to those. But you shouldn't start there."

• Avoid: Certain newer diabetes drugs have been associated with heart failure and other risks.

Avandia, for example, has been linked to an increased risk of heart attacks. In September 2010, after years of debate, the Food and Drug Administration severely restricted Avandia's availability, allowing it to be prescribed only to patients in a special program who had not responded to other drugs and were taking the medicine under a doctor's strict supervision. This month the agency expanded those restrictions to include related drugs Avandamet and Avandaryl, which also contain rosiglitazone, the active agent in Avandia.

• Step 3: Choose combination drugs from among inexpensive generics.

Cost: Glimepiride, $13 for 100 pills (1 milligram). Glipizide, $64 for 100 pills (5 milligrams).

Most diabetics will have to eventually take more than one drug to keep blood sugar under control. The good news here from the Johns Hopkins study is that inexpensive metformin is also quite effective in combination with other generics, such as glimepiride and glipizide.

"Most combinations worked equally well, so when you're adding a drug, you could choose a generic to save costs," said Dr. Bennett. She added, however, that some drugs used with metformin might increase the risk of side effects such as hypoglycemia or weight gain. Patients should discuss each drug's pros and cons, as well as cost, with their doctors.

• Avoid: Do not start with one of the more expensive drugs in combination with metformin. In some cases, patients ultimately may need a combination of both generics and the newer drugs, but this usually becomes appropriate only after a less expensive combination has been used for some time or if the patient isn't responding to the less expensive combination, said Dr. Bennett.