FAQ: Why GLP-1 Adherence, Not Access, Decides Value of the DTC Boom

Direct-to-consumer (DTC) channels, telehealth platforms, and 2 new oral options have made it easier than ever to start a glucagon-like peptide-1 receptor agonist (GLP-1 RA). Staying on therapy is a separate problem, and it is the one that determines whether payers see a return on GLP-1 RA spending. In a recent feature, leaders at Shields Health Solutions argued that discontinuation is often a support problem, not a medication problem.¹ The questions below cover what happens when patients stop, why adherence has grown harder to track, and what plans can measure.

How Many Patients Who Stop a GLP-1 RA Restart Therapy?

Fewer than half, and the share depends on why the patient was taking the drug. A retrospective cohort study published in JAMA Network Open followed 125,474 adults with overweight or obesity who started liraglutide, semaglutide, or tirzepatide between 2018 and 2023.² Among patients with type 2 diabetes (T2D) who discontinued, 47.3% had restarted a GLP-1 RA within 1 year, compared with 36.3% of those without T2D. Weight regain after stopping was associated with a higher likelihood of restarting.

That link matters because weight regain comes quickly. In the off-treatment extension of the STEP 1 (NCT03548935) trial, published in Diabetes, Obesity and Metabolism, adults without diabetes who stopped once weekly semaglutide 2.4 mg and lifestyle intervention after 68 weeks regained about two-thirds of their prior weight loss within a year, and most cardiometabolic improvements moved back toward baseline.³ The investigators wrote that the findings confirm obesity is chronic and suggest ongoing treatment is needed to maintain the benefit. For a payer, a stop-start cycle can mean funding titration twice without the durable benefit that justified coverage in the first place.

Why Do Patients Without T2D Stop More Often?

Patients using a GLP-1 RA for weight management alone were more likely to discontinue and less likely to restart than patients with T2D in the same cohort. Within 1 year, 64.8% of patients without T2D stopped therapy, compared with 46.5% of those with T2D.² Greater weight loss was associated with lower discontinuation, as was higher income among patients with T2D. Moderate or severe gastrointestinal adverse events were associated with higher discontinuation in both groups.

Coverage is part of the picture. One of the study's coauthors told Healio that the findings point to a need for policy changes that expand insurance coverage for patients without T2D.⁴ Coverage for that population remains in flux in Medicare, where the temporary GLP-1 Bridge offers eligible beneficiaries GLP-1 RAs for obesity at a $50 copay through the end of 2027.¹

Why Is GLP-1 RA Adherence Harder to Track Through DTC Channels?

Much of it never reaches a claims system. Cash-pay prescriptions, including many filled through DTC channels, do not appear in pharmacy claims data.¹ A plan or health system analyzing its own claims may see a patient start therapy and then appear to stop, without knowing whether that patient moved to a self-pay channel or quit altogether. Even a paid claim does not confirm that the patient took the medication.

Brian Smith, PharmD, chief pharmacy officer at Shields, wrote that providers may have limited visibility into care that happens outside the broader health system. His proposed fix centers on the relationship between the dispensing pharmacist and the prescriber.

"Integrated specialty pharmacy models help address these challenges by connecting pharmacists and prescribers around a shared care plan, enabling proactive outreach and intervention at key points in the patient journey," Smith wrote in a statement to The American Journal of Managed Care^® (AJMC^®).

How Should Plans Measure GLP-1 RA Adherence?

Two widely used metrics measure different things. Proportion of days covered (PDC) captures how consistently a patient has medication on hand over a period, and it is the adherence measure the Pharmacy Quality Alliance has endorsed and CMS has built into its Medicare plan ratings. Researchers have generally treated a PDC of 80% as acceptable in many disease states, although there is no consensus on an optimal threshold.⁵ Persistence, the inverse of discontinuation, captures whether a patient stays on therapy at all, usually defined by a maximum allowable gap between fills.

The choice of gap changes the answer. In a MedScout analysis of pharmacy claims for the 5.1 million patients who started a GLP-1 in 2024, 59% discontinued within the first year when discontinuation was defined as a gap of more than 60 days after a fill's supply ran out. With a 90-day gap, the share was 56%.¹

Shields reports both for its network of nearly 80 health system partners. In its 2025 outcomes report, 19.7% of patients discontinued GLP-1 RA therapy at 1 year, and adherence reached 92%.¹ Jennifer Donovan, PharmD, vice president of clinical services at Shields, told AJMC that the adherence figure is measured by PDC. Those figures reflect Shields' own network and should not be read as a head-to-head comparison with national claims data.

Do Oral GLP-1 RAs Make Adherence Easier?

They widen the options, but they trade one burden for another. The FDA approved an oral formulation of semaglutide for obesity (Wegovy pill) in December 2025 and orforglipron (Foundayo; Eli Lilly) in April 2026, and both are taken once daily rather than once weekly.⁶ Oral semaglutide must be taken in the morning on an empty stomach with a sip of water, followed by a 30-minute wait before eating or drinking. Orforglipron, a small-molecule GLP-1 RA, carries no such restrictions.

That makes patient preference part of the prescribing decision. At Shields’ partner sites, pharmacists learn each patient's preferences on the first call, Donovan said in an interview with AJMC. Some patients do not want injections or have difficulty with them, while others would rather take a weekly shot than a daily pill. Patients who travel often may also weigh whether a medication needs refrigeration. The goal, she said, is to start patients on the medication they will take consistently.

Managed Care Implications

The evidence points to adherence as the variable that decides whether GLP-1 RA spending produces durable results. Patients who stop tend to lose much of their benefit; restarting is more likely after weight has returned, and cash-pay fills never reach a plan's claims data. Coverage that ends at the prescription leaves plans paying for initiation, and sometimes reinitiation, without the outcomes that justified the benefit.

Plans weighing adherence programs can start by agreeing on definitions: which PDC threshold and which allowable gap they will use, and how they will account for patients who move between insured and cash-pay channels. From there, the questions for any vendor or health system partner are concrete. Who contacts the patient before the first fill and again during titration? Does that person have access to the prescriber and the medical record, and does the program report 12-month persistence rather than adherence alone?

References

1. Steinzor P. The DTC GLP-1 boom solved access. Can it solve adherence? AJMC. October 27, 2026. Accessed October 29, 2026. https://www.ajmc.com/view/the-dtc-glp-1-boom-solved-access-can-it-solve-adherence
2. Rodriguez PJ, Zhang V, Gratzl S, et al. Discontinuation and reinitiation of dual-labeled GLP-1 receptor agonists among US adults with overweight or obesity. JAMA Netw Open. 2025;8(1):e2457349. doi:10.1001/jamanetworkopen.2024.57349
3. Wilding JPH, Batterham RL, Davies M, et al; STEP 1 Study Group. Weight regain and cardiometabolic effects after withdrawal of semaglutide: the STEP 1 trial extension. Diabetes Obes Metab. 2022;24(8):1553-1564. doi:10.1111/dom.14725
4. Monostra M. Most adults with overweight or obesity discontinue GLP-1 therapy within 2 years. Healio. January 31, 2025. Accessed October 29, 2026. https://www.healio.com/news/endocrinology/20250131/most-adults-with-overweight-or-obesity-discontinue-glp1-therapy-within-2-years
5. Do you know the difference between these adherence measures? Pharmacy Times^®. July 6, 2015. Accessed October 29, 2026. https://www.pharmacytimes.com/view/do-you-know-the-difference-between-these-adherence-measures
6. Aleccia J. FDA grants speedy approval to Eli Lilly's weight-loss pill for obesity. Associated Press. April 1, 2026. Accessed October 29, 2026. https://abc7ny.com/post/fda-grants-speedy-approval-eli-lillys-weight-loss-glp-1-pill-foundayo-obesity/18823509/