Semaglutide alternatives: sensible choices for weight loss and blood sugar control

If semaglutide isn’t right for you — due to cost, side effects, or access — there are other options that can help with weight loss and blood sugar. Below I cover prescription choices, what to watch for, and non-drug paths you can discuss with your doctor. This is practical info to help you compare alternatives.

Prescription medication alternatives

Tirzepatide (Mounjaro) — A newer injectable that works on GIP and GLP-1 receptors. It often produces larger weight loss than older drugs, but it’s injectable, may cause nausea, and can be costly. If you respond well to GLP-1s, talk to your prescriber about tirzepatide as an option.

Phentermine/topiramate (Qsymia) — An oral combo pill used for weight loss. It can suppress appetite and produce meaningful weight loss for some people. Watch for increased heart rate, mood changes, and birth defect risk if taken during pregnancy. It’s not for long-term use by everyone, so regular follow-up is needed.

Naltrexone/bupropion (Contrave) — An oral combo that affects appetite and reward pathways. It can help reduce cravings and support weight loss when paired with lifestyle changes. Side effects include nausea, insomnia, and increased blood pressure in some people.

Orlistat (Alli, Xenical) — A pill that reduces fat absorption in the gut. It’s available over-the-counter at a lower dose (Alli) and by prescription at higher dose (Xenical). Expect oily stools and need to take fat-soluble vitamins separately. It’s a simple, non-hormonal option.

Metformin — Primarily for blood sugar control in type 2 diabetes, metformin can also modestly reduce weight, especially if insulin resistance is a factor. It’s cheap and well-studied, but benefits on weight are smaller than GLP-1s.

Non-drug and procedural options

Bariatric surgery — Procedures like gastric sleeve or bypass produce the largest, most durable weight loss. Surgery has risks and requires lifelong follow-up, but for people with severe obesity it can greatly improve health markers.

Lifestyle and structured programs — Intensive diet programs, coached weight-loss plans, and medically supervised lifestyle interventions often outperform ad-hoc dieting. Look for programs that include calorie targets, protein guidance, behavioral coaching, and regular check-ins.

Device-based options — Endoscopic procedures (like intragastric balloons) or neuromodulation implants are less invasive than surgery and can support weight loss for months. They’re worth discussing if meds aren’t an option and surgery feels too big.

How to choose: match the option to your goals, health profile, and budget. Ask your clinician about effectiveness, side effects, monitoring needs (labs, pregnancy tests), and insurance coverage. If you’re pregnant, planning pregnancy, or have a history of pancreatitis or certain mental health issues, mention that — it changes which options are safe.

Finally, keep expectations realistic: combining medical options with sustained lifestyle change works best. Track progress, report side effects fast, and reassess every few months to find what truly fits your life and health goals.