What options are available for patients who cannot afford tirzepatide (a glucagon-like peptide-1 receptor agonist) but want to continue treatment?

Affordable Alternatives for Patients Who Cannot Afford Tirzepatide

For patients unable to afford tirzepatide, the most practical alternative is switching to a GLP-1 receptor agonist with proven cardiovascular benefit, particularly if generic options become available, or utilizing patient assistance programs and manufacturer savings programs to maintain access to tirzepatide. 1

Cost Context and Financial Burden

The median monthly cost of tirzepatide (15 mg weekly) is substantial:

• Average Wholesale Price (AWP): $1,228-$1,283 1
• National Average Drug Acquisition Cost (NADAC): $982-$1,030 1

This represents one of the most expensive glucose-lowering and weight management medications available, comparable to other GLP-1 receptor agonists 1.

Primary Alternative Strategies

1. Patient Assistance Programs (PAPs)

Enroll patients in manufacturer-sponsored patient assistance programs, which provide free or reduced-cost medications for qualifying individuals. 2

• Patients must complete applications with personal financial information 2
• These programs serve as a critical safety net for uninsured or underinsured patients 2
• Pharmacist-led enrollment efforts have demonstrated marked reductions in medication access barriers over extended periods 2

Target patients for screening include: 2

• Those without health insurance
• Patients without prescription drug benefits
• Those exceeding Medicaid coverage limits
• Patients with pending insurance coverage
• Individuals for whom tirzepatide is not covered by their insurance

2. Switch to Alternative GLP-1 Receptor Agonists

For patients with type 2 diabetes and established cardiovascular disease, chronic kidney disease, or heart failure, switch to a GLP-1 receptor agonist with proven cardiovascular benefit. 1

The most cost-effective GLP-1 RA options include:

• Dulaglutide (4.5 mg weekly): AWP $1,117-$1,173, NADAC $895-$941 1
• Semaglutide (2 mg weekly): AWP $1,097-$1,162, NADAC $899-$933 1
• Liraglutide (1.8 mg daily): AWP $929-$1,619, NADAC $1,072-$1,296 (generic pricing may become available) 1

Important consideration: While tirzepatide demonstrates superior glycemic control (HbA1c reductions of 1.24-2.58%) and weight loss (5.4-11.7 kg) compared to selective GLP-1 RAs 3, semaglutide remains highly effective with similar cardiovascular benefits 1.

3. Consider Lower-Cost Oral Agents with Proven Benefits

For patients with type 2 diabetes, CKD, and eGFR ≥20 mL/min/1.73 m², prioritize an SGLT2 inhibitor with proven kidney or cardiovascular benefit. 1

SGLT2 inhibitor costs (significantly lower than tirzepatide): 1

• Ertugliflozin (15 mg): AWP $408-$428, NADAC $312-$343
• Dapagliflozin (10 mg): AWP $659-$678, NADAC $352-$543
• Empagliflozin (25 mg): AWP $712-$733, NADAC $569-$586
• Canagliflozin (300 mg): AWP $684-$718, NADAC $548-$574

These agents are recommended independent of metformin use and independent of A1C for patients with established cardiovascular disease, heart failure, or CKD. 1

4. Metformin as Foundation Therapy

Ensure patients are on metformin (if not contraindicated), which remains the most cost-effective glucose-lowering medication: 1

• Metformin 1,000 mg (immediate release): AWP $87, NADAC $1-$2 per month 1
• Metformin 1,000 mg (extended release): AWP $1,884, NADAC $26-$31 per month 1

Metformin is recommended for patients with type 2 diabetes, CKD, and eGFR ≥30 mL/min/1.73 m² 1.

5. Pioglitazone for Specific Indications

For patients with NAFLD/NASH and type 2 diabetes who cannot afford tirzepatide, consider pioglitazone (45 mg): 1

• Cost: AWP $348, NADAC $3-$4 per month 1
• Pioglitazone results in resolution of NASH and may improve fibrosis 1
• This represents exceptional cost-effectiveness for NASH treatment 1

Cautions: Dose-dependent weight gain, increased fracture risk, potential heart failure exacerbation in susceptible patients, and controversial bladder cancer risk 1.

Clinical Decision Algorithm

Step 1: Immediately enroll patient in manufacturer patient assistance program for tirzepatide 2

Step 2: If assistance program insufficient or patient doesn't qualify:

• For patients with established ASCVD, HF, or CKD: Switch to semaglutide or dulaglutide (similar cardiovascular benefits) 1
• For patients with CKD (eGFR ≥20): Add or switch to SGLT2 inhibitor 1
• For patients with NAFLD/NASH: Consider pioglitazone 1

Step 3: Ensure metformin is maximized (if tolerated and not contraindicated) 1

Step 4: For weight management as primary goal without diabetes, consider structured lifestyle modification programs as these may be more accessible than pharmacotherapy 1

Critical Pitfalls to Avoid

Do not abruptly discontinue tirzepatide without a transition plan. Sudden discontinuation results in regain of one-half to two-thirds of weight loss within 1 year 1. Establish alternative therapy before stopping tirzepatide.

Do not assume all GLP-1 RAs have identical cardiovascular benefits. Only specific agents (liraglutide, semaglutide, dulaglutide) have demonstrated cardiovascular outcome benefits in trials 1.

Do not overlook insurance coverage requirements. Healthcare teams must be knowledgeable about coverage requirements and establish systems to support evidence-based prescribing 1.

Do not use metformin in patients with eGFR <30 mL/min/1.73 m², and reduce dose to 1000 mg daily in patients with eGFR 30-44 mL/min/1.73 m² 1.

Advocacy Considerations

Payors should cover evidence-based obesity and diabetes treatments to reduce barriers to treatment access. 1 The substantial cost differential between tirzepatide and alternatives creates significant access disparities that impact patient outcomes.