When You Can't Get Adempas, What Are Your Options?

If you're having trouble filling your Adempas (Riociguat) prescription — whether because of availability issues, insurance barriers, or cost — you may be wondering what other medications can treat your condition. The good news is that several FDA-approved alternatives exist for pulmonary arterial hypertension (PAH) and, in some cases, chronic thromboembolic pulmonary hypertension (CTEPH).

Important: Never switch medications on your own. Always talk to your doctor before making any changes to your treatment plan. The alternatives listed here work through different mechanisms and may not be appropriate for everyone.

If your issue is finding Adempas in stock, you may also want to check our guide on how to find Adempas near you before exploring alternatives.

What Is Adempas and How Does It Work?

Adempas (Riociguat) belongs to a unique drug class — it's a soluble guanylate cyclase (sGC) stimulator. It works by stimulating the sGC enzyme in the walls of pulmonary blood vessels, which increases levels of a molecule called cyclic GMP (cGMP). This causes the blood vessels in the lungs to relax and widen, reducing pulmonary blood pressure and improving blood flow.

Adempas is FDA-approved for:

• Chronic thromboembolic pulmonary hypertension (CTEPH) — in patients with persistent or recurrent CTEPH after surgery, or in patients who cannot have surgery
• Pulmonary arterial hypertension (PAH, WHO Group 1) — to improve exercise capacity and delay disease progression

It's the only FDA-approved sGC stimulator for these conditions, which means there's no direct substitute that works in exactly the same way. However, there are medications in other drug classes that treat the same underlying conditions.

For a more detailed look at how Adempas works in the body, read our guide on Adempas mechanism of action explained.

Alternative Medications for PAH and CTEPH

The following alternatives are FDA-approved for pulmonary arterial hypertension. While none are sGC stimulators like Adempas, they target different pathways involved in pulmonary hypertension and can be effective treatment options.

1. Bosentan (Tracleer)

Drug class: Endothelin receptor antagonist (ERA)

Bosentan blocks endothelin, a substance that causes blood vessels to narrow. By blocking endothelin receptors, Bosentan helps pulmonary arteries relax and reduces blood pressure in the lungs.

• FDA-approved for: PAH (WHO Group 1) to improve exercise ability and slow clinical worsening
• How it's taken: Oral tablet, taken twice daily
• Key considerations: Requires monthly liver function tests due to risk of liver damage. Also available only through a REMS program. Generic versions are available, which may reduce cost
• Estimated cost: Generic Bosentan can run around $1,500 to $3,000/month without insurance — significantly less than Adempas

2. Ambrisentan (Letairis)

Drug class: Endothelin receptor antagonist (ERA)

Like Bosentan, Ambrisentan blocks endothelin receptors, but it's more selective for the endothelin A receptor. This may result in fewer liver side effects compared to Bosentan.

• FDA-approved for: PAH (WHO Group 1) to improve exercise capacity and delay clinical worsening
• How it's taken: Oral tablet, taken once daily
• Key considerations: Does not require routine liver monitoring like Bosentan. Also available through a REMS program due to pregnancy risks. Can cause peripheral edema (swelling)
• Estimated cost: Around $4,000 to $6,000/month for brand; generic versions may be available at lower cost

3. Macitentan (Opsumit)

Drug class: Endothelin receptor antagonist (ERA)

Macitentan is a newer ERA that provides sustained receptor binding in the pulmonary artery tissue. The SERAPHIN clinical trial showed it reduced morbidity and mortality in PAH patients.

• FDA-approved for: PAH (WHO Group 1) to delay disease progression
• How it's taken: Oral tablet, taken once daily
• Key considerations: Carries pregnancy risk (REMS required). Can cause anemia, nasopharyngitis, and headache. Requires hemoglobin monitoring
• Estimated cost: Approximately $8,000 to $12,000/month without insurance

4. Treprostinil (Orenitram, Tyvaso, Remodulin)

Drug class: Prostacyclin analog

Treprostinil mimics the effects of prostacyclin, a natural substance that dilates blood vessels and prevents blood clot formation. It's available in multiple formulations:

• Orenitram — oral extended-release tablets for PAH
• Tyvaso — inhaled solution for PAH and PH associated with interstitial lung disease
• Remodulin — subcutaneous or intravenous infusion for PAH

• FDA-approved for: PAH; Tyvaso is also approved for PH-ILD
• Key considerations: The inhaled and injectable forms require special devices and training. Common side effects include jaw pain, diarrhea, headache, and nausea. The subcutaneous infusion can cause injection site pain
• Estimated cost: Varies widely by formulation — Orenitram can cost $10,000 to $15,000/month; Remodulin infusion can exceed $100,000/year

What About CTEPH Specifically?

It's important to note that Adempas is the only medication specifically FDA-approved for CTEPH. If you have CTEPH (rather than PAH), your options are more limited:

• Pulmonary thromboendarterectomy (PTE) surgery — the primary treatment for operable CTEPH, which can be curative
• Balloon pulmonary angioplasty (BPA) — a catheter-based procedure for patients who can't have surgery or have residual disease after surgery
• Off-label use of PAH medications — in some cases, doctors may prescribe ERAs or prostacyclin analogs off-label for CTEPH, though they're not specifically approved for this indication

If you have CTEPH and can't access Adempas, it's especially important to discuss alternatives with a pulmonary hypertension specialist.

How to Decide Which Alternative Is Right for You

Choosing an alternative to Adempas depends on several factors:

• Your specific diagnosis — PAH and CTEPH have different treatment pathways
• Severity of your condition — some medications are better suited for more advanced disease
• Other medications you take — drug interactions must be considered (see our guide on Adempas drug interactions)
• Side effect profile — each medication has different risks and monitoring requirements
• Cost and insurance coverage — some alternatives are significantly more or less expensive than Adempas
• Your lifestyle — oral medications may be preferable to injectable or inhaled options

Always work with a pulmonary hypertension specialist when considering a switch. These are complex conditions that require expert management. If you need help finding a specialist, check our guide on finding a doctor who prescribes Adempas.

Final Thoughts

While Adempas is the only sGC stimulator available for PAH and CTEPH, there are several alternative medications that can effectively manage pulmonary arterial hypertension. Bosentan, Ambrisentan, Macitentan, and Treprostinil each offer different benefits and come with their own considerations.

Before exploring alternatives, make sure you've exhausted all options for getting Adempas itself. Use Medfinder to check availability, look into financial assistance programs, and work with your doctor's office to navigate the REMS process.

If switching is necessary, trust your pulmonary hypertension specialist to guide you to the right option for your specific situation.