Background: Diabetes is increasing in prevalence and management of comorbid disease in cancer is important for outcomes. Comorbid diabetes mellitus in patients with metastatic hormone sensitive prostate cancer (mHSPC) is important to consider as cancer treatments can adversely affect metabolic health and have added interactions with diabetes medicines. Little is known about the comparative effectiveness of diabetes management with insulin or oral medications. We aim to assess the survival of patients with comorbid diabetes based on insulin, oral, or no medication management. Methods: Patients diagnosed with mHSPC from 2000-2021 were identified within the Veterans Health Administration. Uncomplicated or complicated diabetes was determined using Charlson codes from the International Classification of Diseases. Treatment was determined by prescriptions of insulin, oral medication, or no use in VHA prescription records in the year prior, up to 14 days before diagnosis. Kaplan-Meier, ANOVA, and Cox proportional hazard models were used to analyze the data and covariates such as body-mass index, age, race, and baseline PSA. Results: Patients with mHSPC had significant differences in survival with diagnosis of diabetes, see table. Patients with complicated diabetes had a higher mean BMI than patients with uncomplicated diabetes (28.3 vs. 29.1, p <.001). In patients with diabetes (n = 4740), insulin was used in 1091, oral medication in 1833, or no medicines in 1816. Oral diabetes medication was associated with improved survival compared to insulin and no medication use had the lowest survival (26.6 months vs. 24.3 vs. 21.9, p <0.001). In an adjusted multivariable model, both insulin and oral medicine use were associated with increased risk of death with adjusted Hazard Ratio (aHR) for insulin 1.25 (95% CI 1.17-1.35), for oral medicine aHR 1.11 (95% CI 1.05-1.18). Conclusions: Among veterans with mHSPC, diabetes was associated with decreased survival. Within patients with a diagnosis of complicated or uncomplicated diabetes, the use of oral medication was associated with longer survival compared to insulin. Further assessment of the management of comorbid diabetes may help guide treatment and prevent adverse events.