Paul Miranda, MD

Board-Certified in Family Medicine · Emergency Physician · Obesity Medicine Association member

I’m an emergency and Family Medicine physician in Chattanooga, Tennessee, and founder of Summit Metabolic Health. I read every patient chart personally. This article reports on a topic patients keep asking about — it is education, not an endorsement.

Medically reviewed by Paul Miranda, MD

Patients in my Chattanooga practice ask this question almost every week, and most of them have already read three websites that gave three different answers. That’s not an accident. Most sites answer “which is better” with a thumb on the scale toward whatever drug they stock or profit more from. I don’t have that problem — Summit prescribes both, at the same flat price, so I have no reason to steer you toward either one. What I have instead is the actual trial data, and a chart to read before I answer.

Start with what the trials measured, not what the marketing implies.

SURMOUNT-1 followed adults on tirzepatide for 72 weeks. At the highest studied dose, 15mg, participants lost a mean 20.9% of body weight compared to placebo.¹ STEP 1 followed adults on semaglutide 2.4mg for 68 weeks and found a mean 14.9% weight loss compared to placebo.²

Read those two numbers side by side and tirzepatide looks like the clear winner. On raw average weight loss, at the top dose, in these specific trials, it is. But two trials run in different years, on different populations, with different doses, are not a lab bake-off — they’re two separate looks at two separate drugs. The honest read is: tirzepatide’s ceiling is higher. That’s one fact, not the whole answer.

Here’s where I stop sounding like a spec sheet. Neither drug is “better” in the abstract, because “better” isn’t a property of a molecule — it’s a match between what a drug does and what a patient needs.

I ask every patient the same question before I write either prescription: what are you actually optimizing for? Maximum pounds off the scale? Or a documented reduction in your risk of a heart attack or stroke? Those aren’t the same goal, and right now, the trial evidence doesn’t support both drugs equally on both fronts. That’s the part of this comparison most sites skip, because it doesn’t fit in a headline.

Semaglutide has something tirzepatide does not yet have: a completed cardiovascular outcomes trial. SELECT enrolled over 17,000 adults with established cardiovascular disease and overweight or obesity — no diabetes required — and followed them for a median of 40 months. Semaglutide 2.4mg reduced major adverse cardiovascular events (cardiovascular death, non-fatal heart attack, non-fatal stroke) by 20% compared to placebo.³

I work ER shifts. I see the version of this that goes wrong — the chest pain, the stroke, the patient who didn’t know their risk was climbing. A 20% cut in major cardiac events in a population that already has heart disease is not a marketing claim. It’s a documented outcome in a peer-reviewed trial, published in the New England Journal of Medicine. For a patient with known cardiovascular disease, that’s not a footnote. That’s the deciding fact.

Tirzepatide hasn’t been trialed to show this. Its own cardiovascular outcomes trial, SURMOUNT-MMO, is still running. That doesn’t mean tirzepatide is unsafe for the heart — it means the same level of proof simply doesn’t exist yet. Absence of evidence isn’t evidence of absence, but I don’t prescribe on a hunch about what a future trial might show. I prescribe on what’s published today.

Tirzepatide’s advantage is real and it’s the one everyone already knows: more weight loss, on average, than semaglutide produced in its own trial. For a patient whose priority is the largest achievable reduction in body weight — someone with a high starting BMI, significant weight-related joint or mobility limitations, or a personal goal that genuinely requires more — that ceiling matters.

Tirzepatide works on two gut hormone receptors instead of one: GLP-1 and GIP. That dual mechanism is the likely driver of the larger average effect size in SURMOUNT-1. It also tends to come with a different side effect texture than semaglutide for some patients — something I cover with every patient I start on it, and something I’ve written about separately for anyone comparing tirzepatide’s most common side effects against semaglutide’s.

Ro, Hims, Henry Meds, and Found are protocol-driven platforms, not physician practices in the way Summit is. Their recommendation engine is shaped by what they stock and what maximizes margin under their current brand-only pricing, which sits between $448 and $498 a month post-cliff. A platform built to route you toward inventory can’t also be the platform that reads your actual cardiac history and asks whether SELECT’s findings change your answer.

That’s not a knock on the drugs — it’s a structural limit. A checkbox intake form doesn’t know your family history of heart disease. It doesn’t know you’d rather trade some weight-loss ceiling for a documented cardiac protection benefit. A physician reading your chart does. That comparison — real numbers plus judgment applied to your specific history — is what a protocol can’t produce, no matter how polished the app is.

At Summit, I personally review every chart before either drug gets prescribed. Not a nurse queue, not a form that auto-routes you to whichever medication is in stock that week. If you have established cardiovascular disease, or a family history that puts you at meaningfully elevated risk, we talk through SELECT’s numbers directly, and semaglutide is usually where that conversation lands. If your priority is the largest achievable weight loss and your cardiac risk is otherwise unremarkable, tirzepatide’s SURMOUNT-1 numbers are usually the stronger fit. Some patients start on one and switch after we see how their body responds — that’s a conversation, not a locked-in decision made at intake.

Cost matters here too, and I’ll be direct about it the same way I am with the trial data: our pricing is flat and disclosed up front, with a descending-dose structure as you move toward maintenance, not a subscription that quietly climbs. You can read the actual numbers on our medical weight loss pricing page before you ever talk to me.

Neither drug is universally “better.” One has a proven cardiac protection benefit; the other has a higher average ceiling on weight loss. Which one is right for you depends on which of those two facts matters more for your specific history — and that’s a conversation a chart review can have that a checkout flow can’t.

Ready to start? Apply at summitmetabolichealth.com/apply.

For more on GLP-1 medications and metabolic health, visit the Summit blog.

This post is educational and does not replace individualized medical advice. Trial results reflect group averages and do not guarantee individual outcomes.

Sources: 1. Jastreboff AM, et al. “Tirzepatide Once Weekly for the Treatment of Obesity.” NEJM 2022 (SURMOUNT-1). 2. Wilding JPH, et al. “Once-Weekly Semaglutide in Adults with Overweight or Obesity.” NEJM 2021 (STEP 1). 3. Lincoff AM, et al. “Semaglutide and Cardiovascular Outcomes in Obesity without Diabetes.” NEJM 2023 (SELECT).