Real-world studies of GLP-1 discontinuation showed that patients often regain weight at a significantly faster pace than after other weight-loss methods. At the same time, however, novel strategies aimed at countering those effects are showing promise.
The heightened interest in alternatives comes amid reports estimating that 50%-65% of patients prescribed GLP-1s discontinue treatment within the first year, despite the well-documented risk for weight regain. Common contributors to discontinuation include cost, side effects, and insurance coverage barriers.
A recent meta-analysis published in The BMJ highlighted how quickly weight can return after GLP-1 discontinuation.
Compared with patients who had lost weight through behavioral weight-loss programs such as low-calorie diets, those stopping GLP-1s were projected to regain weight about four times faster and return to baseline weight 2.4 years sooner, the authors reported.
The analysis included 37 studies involving antiobesity medications used for an average of 39 weeks, with an average 32-week follow-up after treatment discontinuation. On average, patients taking semaglutide or tirzepatide regained approximately two thirds of their lost weight within a year after stopping therapy, with return to baseline weight projected to occur within about 1.5 years.
The average monthly rate of weight regain was 0.4 kg (0.88 lb), exceeding regain rates observed after bariatric weight-loss programs by 0.3 kg/mo, independent of the initial weight loss achieved.
Cardiometabolic improvements also appeared short-lived after treatment cessation. The analysis projected that most benefits would return to baseline levels within 1.4 years after stopping antiobesity medications.
“We were surprised by how quickly the weight was regained, especially as our previous review showed a much slower rate of regain after behavioral weight management programs,” senior author Dimitrios A. Koutoukidis, PhD, of the Nuffield Department of Primary Care Health Sciences at the University of Oxford, Oxford, England, told Medscape Medical News.
The findings also raise important questions about coverage decisions for GLP-1s by insurers and healthcare systems, such as the UK’s National Health System.
“If long-term treatment is needed to sustain weight and the associated clinical benefits of semaglutide, this will considerably increase the cost of treatment, eroding cost effectiveness,” Koutoukidis and colleagues wrote in a separate commentary in The BMJ.
Real-World Data Reveal Subgroup Patterns
The issue of weight regain following discontinuation was the focus of another study, published in March in Diabetes, Obesity and Metabolism. Researchers conducted a real-world analysis of 7938 patients in the Cleveland Clinic health system who discontinued semaglutide or tirzepatide.
Among patients who stopped treatment within 3-12 months of initiation, weight loss prior to discontinuation was nearly twice as high for those prescribed the drugs for obesity (-8.4%) compared with those treated for type 2 diabetes (-4.4%). After discontinuation, 55.4% of patients treated for obesity regained weight vs 43.6% of those treated for type 2 diabetes.
Patients with type 2 diabetes were also more likely to restart their original medications than those treated for obesity (23.5% vs 14.2%), likely reflecting broader insurance coverage for type 2 diabetes indications currently, the authors hypothesized.
Among the 35.2% of other patients who received alternative obesity treatments following discontinuation, 27.4% of patients started a different medication, 13.7% pursued lifestyle modification, and 0.6% underwent metabolic and bariatric surgery.
Decisions to reinitiate the original medication or receipt of alternative obesity treatment “may explain why patients regained less weight than patients in randomized trials,” first author Hamlet Gasoyan, PhD, MPH, assistant professor of medicine at the Cleveland Clinic Lerner College of Medicine of Case Western Reserve University in Cleveland, told Medscape Medical News.
Gasoyan and colleagues emphasized the future studies are needed to compare different obesity treatments among those discontinuing GLP-1 therapy, a common clinical area for which evidence-based guidelines currently do not exist.
Endoscopic Procedures When GLP-1s Drop Out
Two studies presented in May at Digestive Disease Week (DDW) 2026 evaluated novel endoscopic procedures to prevent weight regain after stopping GLP-1 RAs.
In the first, endoscopic sleeve gastroplasty (ESG), a nonsurgical approach that reduces stomach volume by approximately 70%, produced significantly greater ongoing weight-loss strategy than other post-GLP-1 strategies.
The multicenter study included 103 patients who discontinued semaglutide or tirzepatide and were subsequently treated with one of several alternative interventions for 12 months. Patients treated with ESG (n = 42) achieved 17.9% total weight loss, compared with 5% among patients who switched from semaglutide to tirzepatide (n = 35; P < .0001), and just 0.8% among those using lifestyle modification alone (n = 26; P = .02 vs GLP-1 switch).
All three groups achieved comparable weight loss of about 5.0% while receiving their original GLP-1 treatment.
No serious adverse events occurred in any of the groups, and all endoscopy procedures were performed in an outpatient setting with same-day discharge.
Although ESG is already approved by the FDA and widely available, “this is the first time someone has evaluated the use of an endoscopic weight-loss procedure as an ‘off-ramp’ strategy to help patients maintain weight loss after stopping GLP-1 therapy,” first author Pichamol Jirapinyo, MD, MPH, associate director of bariatric endoscopy and assistant professor of medicine in gastroenterology, hepatology, and endoscopy at Harvard Medical School in Boston, told Medscape Medical News.
Given that cost remains a key reason for initial GLP-1 discontinuation, ESG’s price tag of approximately $12,000 would seem a challenge. However, Jirapinyo noted that “we are actually seeing an interesting shift in the insurance landscape right now.”
“While more payors are restricting or discontinuing coverage for GLP-1 medications because of the ongoing long-term costs, some are beginning to cover one-time weight-loss procedures such as ESG,” she said.
With ESG demonstrating durable weight loss spanning at least 10 years, compared with the need for ongoing GLP-1 treatment, insurers may view it as “a durable, one-time intervention as the more economically sustainable option long term,” she added.
Duodenal Mucosal Resurfacing
The second DDW 2026 study evaluated duodenal mucosal resurfacing, an investigational endoscopic procedure designed to induce what investigators described as a “metabolic reset” by removing a layer of the duodenal mucosa.
As reported by Medscape Medical News, patients undergoing the producer following tirzepatide discontinuation experienced a 2.5% total body weight loss over 3 months, compared with approximately 10% weight regain in a sham-procedure arm.
“What’s particularly encouraging is that the benefit appears to increase over time rather than fade, and that it behaves like a drug in terms of dose response,” lead author Shelby Sullivan, MD, director of the Endoscopic Bariatric and Metabolic Program at Dartmouth Health Weight Center and professor of medicine at Dartmouth Geisel School of Medicine in Hanover, New Hampshire, said in a DDW press statement.
“That gives us confidence that we’re targeting the right biology,” she said.
Commenting on these endoscopic approaches, Koutoukidis noted that even full bariatric surgery remains more cost-effective than long-term GLP-1 therapy.
“For people with severe and complex obesity, bariatric surgery remains substantially more cost-effective than current medications,” he explained.
“In the United Kingdom, estimates are around £7000 [about $9470] per quality-adjusted life year [QALY] for surgery compared with roughly £21,000 [about $28,400] per QALY for GLP-1 medications,” he explained.
“Although surgery has a higher upfront cost, the weight loss is typically larger and maintained for longer, meaning the cardiometabolic benefits are also more durable,” he added.
“The main limitation to wider access is not effectiveness, but insufficient healthcare funding and capacity.”
New Oral GLP-1 an Alternative for Maintenance?
Additional evidence for post-GLP-1 weight maintenance comes from the recently FDA-approved once-daily oral GLP-1 orforglipron, which previously demonstrated weight loss and cardiometabolic improvements compared to injectable GLP-1s.
In the ATTAIN-MAINTAIN study, published in Nature Medicine, patients who had reached a weight plateau after tirzepatide treatment in the SURMOUNT-5 study (n = 205) maintained 74.7% of their prior body weight reduction over 1 year when treated with orforglipron compared with 49.2% among those receiving placebo.
In addition, 43.7% of patients receiving orforglipron group maintained at least 80% of their prior weight loss compared with 16.4% with placebo.
Among patients previously treated with semaglutide (n = 171), weight-loss maintenance rates were 79.3% with orforglipron vs 37.6% with placebo, whereas 55% of orforglipron patients maintained at least 80% of weight loss compared with only 6.9% in the placebo group.
“These data demonstrate orforglipron’s potential as a globally scalable option for minimizing weight changes after injectable therapy,” the study authors wrote.
More broadly, Koutoukidis emphasized that antiobesity medications should be viewed as one component of a wider obesity treatment portfolio.
“Clinicians should use these findings to help set realistic expectations with people taking these medications about the likely duration of treatment needed to maintain weight loss,” he said.
Koutoukidis and Gasoyan reported having no relevant disclosures related to the research discussed in this article. The ESG study was funded by Boston Scientific. Sullivan disclosed consulting and/or relationships with Fractyl Health, Biolinq, and Olympus. Jirapinyo reported being a consultant for Boston Scientific. The ATTAIN-MAINTAIN study was funded by Eli Lilly and Company.
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