How healthcare brands can harness connected ecosystems, real-world data and direct-to-patient relationships to drive persistence in the era of subscription-like treatments
Claire Gillis
CEO, VML Health
GLP-1s are the first blockbuster class where pharma's revenue behaves like a subscription. The upshot? When a cash-pay patient stops treatment in month three, that isn’t just an adherence statistic. It’s lost revenue.
And stopping is only the half of it. Some patients pause… then go elsewhere. Within a year of stopping, more patients switch to a rival drug than go back to the one they left.1 In a subscription business, that’s the worst kind of cancellation: the customer doesn't leave the category, they leave you.
Pharma has spent decades learning to win the start: generating demand, shaping prescribing, securing access. But keeping patients on treatment has received just a fraction of that commercial attention.
In GLP-1s, the winners will be the brands that win the stay. And win back the pause.
Persistence is already becoming a key differentiator, but much of pharma isn't measuring it as a competitive metric. Few patients stay the course: according to a 2025 US study, just 8.1% of people starting a GLP-1 for obesity were still on treatment three years later.²
But first-year persistence is improving fast, and that's where brands are starting to separate. Among commercially insured US patients who started in early 2024, 65% of Zepbound starters were still on treatment after a year, against 59% for Wegovy.³
These retention rates are commercial outcomes hiding in plain sight. And in a cash-pay market they translate directly into revenue.
The scale of the opportunity is considerable. Picture ten people who use a GLP-1. At any one moment, about three of them are off the drug. But only one has likely stopped for good. The other two are pausing and expect to go back.4
That makes returning patients a significant market, potentially rivalling new patients in scale. And arguably a cheaper one to win because they already know the category works for them.
However, with cost, insurance and side effects among the main reasons people stop treatment, there’s no guarantee returning patients will choose the same drug when they come back. Cheaper options and new oral formulations will compete hard for their business. The brand that stays useful during the pause – helping with cost, side effects and what comes next – will likely win.
So far, the obesity evidence race has been about one number: how much weight. The next race is about how well the result holds, and on what terms. That means new questions. How long do patients stay on treatment in routine care? What maintenance dose keeps the benefit at the lowest cost and side-effect burden? What happens when a patient pauses, and how should a restart be managed?
What happens after treatment stops is particularly revealing. Trials have shown as much as two thirds of lost weight returns within a year of stopping.5,6,7 Yet real-world data from Cleveland Clinic found obesity patients who stopped had regained, on average, just 0.5% of body weight a year later, partly because many restarted or moved to another treatment.1
The takeaway: in real life, treatment runs in cycles. Patients stop, restart and switch. Today's persistence measures, which count only unbroken time on treatment, miss most of that story.
The credible evidence will come from real-world data, registries and pragmatic studies, not just randomised trials that keep patients on treatment by design. Manufacturers with their own consented direct-to-patient relationships will hold some of the best of that data. The goal is evidence for the right duration of treatment for the right patient, not for maximum use.
Public payers raise the stakes, but their interest is cost-effective duration, not maximum duration. Since July 2026, Medicare has covered obesity GLP-1s through a temporary demonstration that runs to the end of 2027, and what follows is still unclear.8 Medicare keeps its members for life, so in principle it is the payer best placed to value long-term outcomes. But every extra month on treatment is also a cost it carries, and evidence that GLP-1s offset other medical spending in obesity is still contested.
So payers are likely to reward evidence that treatment is used well: the right patients, sustained where it works, stepped down where it can be. That’s a higher bar than persistence alone, and it favours manufacturers who can show it.
Winning the stay is a different commercial model, not a bigger adherence programme. It asks for four shifts.
Importantly, all of this has to stay clinically led. Pushing patients back onto treatment regardless of need would feed the overprescribing backlash and erode the trust these brands depend on.
Pharma has mastered winning the start. The next era belongs to those who win the stay… and win back the pause.
1 Gasoyan H, Schulte R, Boyer CB, et al. Obesity Treatments and Weight Changes in Clinical Practice After Discontinuation of Semaglutide or Tirzepatide. Diabetes, Obesity and Metabolism. 2026;28(6):4795–4805. 2 Urick BY, Marshall LZ, Gleason PP. GLP-1 Therapy to Treat Obesity Among Members Without Diabetes: Three-Year Persistence and Year-Over-Year Persistence Rate Change. Prime Therapeutics. 2025. 3 Marshall LZ, et al. Trends in 1-year persistence and adherence among initiators of high-potency, weight loss–indicated glucagon-like peptide 1 receptor agonists. J Manag Care Spec Pharm. 2026;32(3):281-291. 4 Caffey A, Gemignani F, Taylor L, et al. The Unexpected Ways GLP-1s Are Transforming Consumer Behavior. Boston Consulting Group. 6 August 2026. 5 Wilding JPH, Batterham RL, Davies M, et al. Weight regain and cardiometabolic effects after withdrawal of semaglutide: The STEP 1 trial extension. Diabetes, Obesity and Metabolism. 2022;24(8):1553–1564. 6 Horn DB, Linetzky B, Davies MJ, et al. Cardiometabolic Parameter Change by Weight Regain on Tirzepatide Withdrawal in Adults With Obesity: A Post Hoc Analysis of the SURMOUNT-4 Trial. JAMA Internal Medicine. Published online 24 November 2025. 2026;186(2):157–167. 7 Aronne LJ, Sattar N, Horn DB, et al. Continued Treatment With Tirzepatide for Maintenance of Weight Reduction in Adults With Obesity: The SURMOUNT-4 Randomized Clinical Trial. JAMA. 2024;331(1):38–48. 8 Freed M, Cubanski J, Williams E. What to Know About the BALANCE Model for GLP-1s in Medicare and Medicaid and the Medicare GLP-1 Bridge. KFF. 11 May 2026.