Today, we’re tackling a question that comes up often in peptide, weight loss, and nutrition clinics: why does one person see great results with semaglutide, while another responds better to tirzepatide—or even retatrutide?
All three peptides target the incretin system, but they act in slightly different ways—and those differences can dramatically affect outcomes.
Let’s start with the basics.
Semaglutide is a GLP-1 (glucagon-like peptide-1) receptor agonist. It mimics the gut hormone GLP-1, which increases insulin when blood sugar is high (to help lower blood sugar), suppresses glucagon (which also decreases blood sugar), and slows gastric emptying. It also enhances satiety—so you feel full longer and eat less.
Tirzepatide is a dual agonist, acting on both GLP-1 and GIP receptors. GIP—glucose-dependent insulinotropic polypeptide—also helps with insulin secretion to lower blood sugar, increases fat metabolism, and may reduce some of the GI side effects seen with GLP-1 alone.
Retatrutide, the newest in the lineup, is a triple agonist that targets GLP-1, GIP, and glucagon receptors. Retatrutide lightly activates the glucagon receptor while strongly activating GLP-1 and GIP receptors, which help regulate blood sugar and boost insulin secretion. This keeps blood sugar stable—or even improves it.
Beyond blood sugar, glucagon also ramps up metabolism and calorie burning. By gently engaging glucagon receptors, retatrutide can increase energy expenditure and support fat loss without triggering large blood sugar spikes.
So how do you decide which one might work best? Let’s walk through common clinical situations.
Patients with Hypothyroidism
Let’s talk about hypothyroidism. People with hypothyroidism often have slower metabolism, making weight loss more difficult even with a balanced diet. Low thyroid hormone levels slow calorie burning and energy use, so weight gain can occur more easily.
For these patients, semaglutide is a reliable starting point—it helps regulate appetite and caloric intake. If progress plateaus, tirzepatide or retatrutide may provide an edge by boosting energy expenditure and fat oxidation, essentially “jump-starting” a slower metabolism.
Patients with PCOS (Polycystic Ovary Syndrome)
What about patients with PCOS (polycystic ovary syndrome)? Insulin resistance is common in PCOS, often leading to higher androgen levels (e.g., testosterone) and symptoms like irregular periods, acne, and excess hair growth. Hormonal changes also affect appetite-regulating hormones, increasing hunger and cravings.
Both GLP-1 and dual agonists have proven effective in managing metabolic and reproductive aspects of PCOS. Typically, we start with semaglutide to improve weight, insulin sensitivity, androgen levels, and menstrual regularity.
After a few months, if weight loss plateaus or cravings remain high, we may switch to tirzepatide. The added GIP activity enhances fat metabolism, insulin control, and may further support hormone regulation and ovulation.
The key is starting with what’s well-studied and tolerated, then stepping up if additional metabolic or reproductive support is needed.
Type 2 Diabetes (T2DM)
The next medical condition I’d like to talk about is type 2 diabetes (T2DM). Weight gain in T2DM often stems from insulin resistance. Cells don’t respond effectively to insulin, prompting the pancreas to relelase more. High insulin levels encourage fat storage, particularly around the abdomen, while elevated blood sugar can increase hunger and cravings. Some diabetes medications, like insulin or sulfonylureas (e.g., glipizide or glyburide), can also contribute to weight gain.
All three drugs lower blood sugar and promote weight loss, but tirzepatide currently shows the strongest combined A1c reduction (average blood sugar over the past 2 to 3 months) and weight loss. GIP and GLP-1 work together to enhance insulin response more effectively than GLP-1 alone.
Retatrutide is in phase 3 trials, with potential FDA approval as early as 2027. Its glucagon receptor activity may offer additional glucose regulation and energy expenditure benefits.
Patients with >15% Weight Loss Goals
Okay, let’s talk about weight loss goals and how this ties into the decision process for choosing a weight loss medication. For those patients looking to lose more than 15% of their total body weight, tirzepatide or retatrutide are likely to deliver greater results. Clinical data show semaglutide can achieve up to 15% total weight loss while tirzepatide can achieve up to 22% and retatrutide up to 24%.
That said, semaglutide remains a highly effective option for weight loss. However, if progress begins to plateau, transitioning to a dual or triple agonist may help restart weight loss and push past that plateau.
Pre- and Postmenopausal Women
What about peri- and postmenopausal patients? Hormonal shifts during perimenopause and menopause slow metabolism and can increase cravings. Declining estrogen promotes abdominal fat storage and affects appetite-regulating hormones.
Semaglutide helps with appetite control and gradual fat loss, while tirzepatide’s GIP activation can further support fat metabolism when estrogen levels drop.
Patients with Heart Disease or High Cholesterol
The last group of patients I’d like to discuss is patients with heart disease (e.g., heart failure, stroke, heart attack, or even atherosclerosis) or people with high cholesterol. Semaglutide has the strongest cardiovascular outcomes data, reducing major adverse cardiac events by 20% and improving LDL cholesterol (bad cholesterol) and blood pressure.
Tirzepatide shows promise for heart and lipid benefits, but those trials are still ongoing. For patients with prior heart attack, stroke, or severe coronary artery disease, semaglutide remains the safest evidence-backed starting point—unless intolerable side effects or weight loss resistance occur.
Tolerability
Now I want to switch gears a bit and talk about side effects and tolerablity of these peptides. Some patients experience stomach-related side effects like nausea, bloating, or acid reflux on semaglutide. Generally, tirzepatide tends to cause fewer GI side effects, likely due to GIP balancing GLP-1 activity in the gut. So patients struggling with nausea or other stomach-related side effects may find tirzepatide more tolerable. Just something to keep in mind.
Individualizing Therapy
Lastly, I want to highlight the importance of individualizing weight loss peptide treatments. There’s no one-size-fits-all approach when it comes to these therapies. Clinicians should carefully consider a patient’s goals, medical history, current medications, and tolerance before choosing the most appropriate option.
Setting realistic expectations from the start is essential. It’s important to remember that everyone’s body responds differently because of factors like hormones, genetics, metabolism, gut microbiome balance, and lifestyle habits. These differences influence how effectively a peptide therapy works and how well it’s tolerated.
That’s why ongoing monitoring and follow-up are such an important part of the process. Providers track progress, adjust dosing when needed, and switch medications if weight loss plateaus or side effects occur. The goal isn’t just to lose weight quickly—it’s to create a safe, sustainable plan that supports long-term metabolic health and helps patients feel their best.
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Until next time, be well, and have a happy, healthy week.
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