Maintenance Therapy on Weight Loss Medications: Wegovy and Mounjaro

In the journey of weight loss, medications like Wegovy (semaglutide) and Mounjaro (tirzepatide) have emerged as groundbreaking options. They work by mimicking hormones that regulate appetite and insulin levels, helping patients lose weight when combined with diet and exercise. However, long-term use and the decision to discontinue these medications bring up important questions. Below, we delve into critical considerations around maintenance therapy with Wegovy and Mounjaro. 

Can I stay on a GLP-1 Mounjaro or Wegovy forever? 

Technically, yes, but whether you should stay on these medications long-term depends on several factors.  

These include: 

• Medical necessity: Patients with obesity or obesity-related conditions (like Type 2 diabetes) may need prolonged therapy to maintain weight loss and control underlying conditions. For some, weight regain after stopping the medication is a significant concern so that ongoing use could be recommended. 
• Tolerance and side effects: Long-term use is feasible for many, but evaluating your body’s tolerance is essential. Side effects like nausea, gastrointestinal issues, or even rare, more serious risks (e.g., thyroid tumours) must be monitored. Regular check-ins with our clinician are critical. 
• Health goals and BMI: Your continuation depends on your weight loss goals, BMI, and overall health. For example, if you achieve and maintain a healthy weight and lifestyle, our provider may reassess the need for the medication. 
• Cost: These medications can be expensive. Cost can become a limiting factor for indefinite use. 

While there are no specific licensing restrictions or duration limits on these treatments, it would be unethical for me as a clinician to apply a one-size-fits-all approach and prescribe these prescription-only medications indefinitely to every patient who has used a GLP-1. 

Ultimately, the decision to remain on Mounjaro or Wegovy long-term should be personalised and discussed with our clinician. The balance of benefits, risks, and individual health goals must be considered. In cases where the benefits are significant—such as for patients with PCOS, insulin resistance, diabetes, or difficulty maintaining weight—extended use should be warranted. 

Is there a BMI where you will stop prescribing for me? 

Yes, BMI is a critical factor in prescribing weight loss medications. Let’s break down the role BMI plays: 

Understanding BMI: Body Mass Index (BMI) is a measure that correlates height and weight to categorise individuals into different weight ranges. The general classifications are: 

• Underweight: BMI < 18.5 
• Average weight: BMI 18.5–24.9 
• Overweight: BMI 25–29.9 
• Obese: BMI ≥ 30 

• Healthy BMI: A BMI between 18.5 and 24.9 is considered healthy. Once a patient achieves a BMI in this range and maintains a stable, healthy lifestyle, the need for continued medication might be reconsidered. 
• When we stop prescribing: As a general guideline, we would stop prescribing weight loss medications that started using Mounjaro/Wegovy at a BMI of 30 or over to individuals with a BMI less than 19. This is to avoid becoming underweight, which can lead to various health issues such as nutritional deficiencies, weakened immune function, and bone health problems. 

Your BMI and overall health status are critical in determining whether to continue, adjust, or stop the medication. 

Will I gain weight if I stop using Mounjaro or Wegovy?  

As observed in clinical studies, weight regain is possible after discontinuing Mounjaro or Wegovy. One of the most notable studies, SURMOUNT-4, demonstrated that many patients experienced weight regain after stopping Mounjaro. This is because, once the medication is discontinued, appetite and metabolism may return to their pre-treatment states, making it harder to maintain weight loss. 

This highlights the importance of continued lifestyle modifications and medical oversight to sustain the benefits of the initial weight loss, whether or not the medication is ongoing. 

Summary of the SURMOUNT-4 Study on Tirzepatide for Weight Maintenance 

The SURMOUNT-4 trial, published in JAMA, investigated whether continued use of tirzepatide (Mounjaro) could help maintain weight loss in adults with obesity or overweight. This study enrolled 670 participants who initially received tirzepatide for 36 weeks, achieving an impressive average weight reduction of 20.9%. Afterwards, participants were randomised to either continue tirzepatide or switch to a placebo for another 52 weeks. 

The findings showed that: 

• During the double-blind period, participants who continued taking tirzepatide lost an additional 5.5% of their body weight. 
• Those who switched to placebo regained 14% of their lost weight. 
• By the end of the study, 89.5% of those continuing tirzepatide maintained at least 80% of their weight loss, compared to just 16.6% of those on placebo. 

The study highlights the importance of continuing tirzepatide to maintain and further enhance weight loss, as discontinuing the drug led to substantial weight regain. Participants also experienced improvements in cardiometabolic factors (e.g., blood pressure and glucose levels) while on the medication. 

However, gastrointestinal side effects such as nausea, diarrhoea, and vomiting were more common among those continuing tirzepatide. These side effects were mild to moderate, and the frequency decreased over time. 

What Should I Do if I Stop Mounjaro?  

If you and our clinician decide that it’s time to stop Mounjaro, diet and lifestyle changes will play a critical role in maintaining your weight loss. Here are some key recommendations: 

• Adopt a balanced diet: Focus on whole foods, such as fruits, vegetables, lean proteins, and whole grains. Avoid highly processed foods, sugary beverages, and excessive fat intake. Portion control is also essential in maintaining your weight. 
• Regular physical activity: Exercise is crucial for maintaining weight loss. Incorporate cardiovascular activities (e.g., walking, running, cycling) and strength training exercises to help boost metabolism and preserve muscle mass. 
• Mindful eating: Pay attention to hunger and fullness cues, and avoid emotional or stress-related eating. Mindful eating practices can help sustain weight loss over the long term. 
• Consistency is key: Maintaining a consistent eating and exercise routine helps prevent weight regain. Developing sustainable habits that fit your lifestyle is more effective than short-term or drastic changes. 
• Seek ongoing support: Whether through a dietitian, support group, or healthcare provider, having ongoing accountability and encouragement can help you stay on track. 

What happens to my metabolism over time if I get used to a good diet and lifestyle? 

A consistent, healthy diet and active lifestyle can profoundly affect your metabolic system. Here’s how your body responds over time: 

• Improved metabolism: Regular exercise, especially strength training, can increase your muscle mass, boosting your basal metabolic rate (BMR). This means your body burns more calories at rest, making maintaining weight easier. 
• Insulin sensitivity: A healthy diet rich in whole foods and low in processed sugars can improve insulin sensitivity, reducing your risk of Type 2 diabetes. This means your body becomes more efficient at using blood sugar for energy, preventing it from being stored as fat. 
• Lowered inflammation: A balanced diet rich in antioxidants and anti-inflammatory foods (e.g., fruits, vegetables, omega-3 fatty acids) can reduce chronic inflammation, promoting better overall health and lowering the risk of metabolic syndrome. 
• Long-term weight stability: By improving your metabolism and regulating blood sugar levels, you’ll find it easier to maintain a stable weight. Over time, your body adapts to these new habits, making you less likely to experience dramatic weight fluctuations. 
• Cardiovascular benefits: Exercise and a heart-healthy diet can lower blood pressure, cholesterol, and triglycerides, significantly reducing your risk of heart disease. 

So, staying on a GLP-1 forever may be unnecessary if your diet and lifestyle improve.  

Can I go back to Mounjaro/Wegovy if I see weight gain after stopping? 

Yes, if you experience significant weight gain after stopping Mounjaro or Wegovy, we can consider restarting the medication. We offer protection for up to 12 months after discontinuation, during which time we will monitor your progress and determine if resuming treatment is appropriate. However, the weight gain needs to be substantial enough to warrant restarting the medication, and it’s essential that you have been my patient from the beginning of your treatment. This ensures that we comprehensively understand your medical history and weight management needs, allowing us to make the best decision for your health. 

Will you provide me maintenance treatment if I was to come from another provider? 

It depends. We will not provide maintenance treatment if your BMI is less than 25 if you are not our patient. This is because we do not have a comprehensive understanding of your medical history and weight management needs, which is essential for making the best decision for your health. If your BMI is above 25, we will take you on. Still, you will need to provide evidence of your current Mounjaro treatment, including documentation from your previous provider, so that we can assess your eligibility for continued care. Ensuring we have the necessary information helps us deliver safe and effective treatment. 

What are the side effects and risks of staying on a GLP-1 like Mounjaro or Wegovy forever? 

 GLP-1 agonists, like Mounjaro (tirzepatide) and Wegovy (semaglutide), have gained widespread popularity as effective treatments for weight loss and diabetes management. They work by mimicking the effects of glucagon-like peptide-1 (GLP-1), a hormone crucial in regulating appetite and blood sugar. However, long-term use of these medications raises essential questions about potential risks and side effects, especially for those considering lifelong therapy. 

While these medications are hailed as game-changers in the treatment of obesity and diabetes, much like insulin was nearly a century ago, the long-term consequences of their use are not fully understood. Below, we explore the potential side effects and concerns about staying on GLP-1 agonists for the long haul. 

Known short-term side effects 

Commonly reported side effects of GLP-1 agonists include: 

• Gastrointestinal issues: Nausea, vomiting, and diarrhoea are the most frequently experienced side effects, often occurring during the early stages of treatment. 
• Injection-site reactions: Some people experience mild irritation or discomfort at the injection site. 
• Pancreatitis risk: There have been reports of acute pancreatitis associated with GLP-1 drugs. Though rare, this risk requires monitoring, especially in patients with a history of pancreatitis. 

These side effects are well-documented, especially within the first few months to years of treatment. Most people’s symptoms tend to decrease as their bodies adjust to the medication. 

Uncertainty Around Long-Term Risks 

While GLP-1 agonists have been FDA-approved and prescribed for over two decades, long-term studies have yet to fully capture the consequences of using these drugs for many years or even a lifetime. Science, a leading journal, highlighted the “uncertainty and even foreboding” around the long-term effects of these medications. Given that these drugs are relatively new for weight loss (as opposed to diabetes treatment), most research has not extended beyond seven years of follow-up. 

Some potential long-term risks include: 

• Unknown metabolic consequences: GLP-1 drugs manipulate a complex physiological system that regulates hunger, blood sugar, and the storage and use of nutrients. Over time, this manipulation could have unforeseen effects on metabolic health, similar to how insulin therapy—though lifesaving—contributed to complications like atherosclerosis and weight gain in some patients. 
• Sustained weight loss vs. weight regain: Like insulin, the benefits of GLP-1 agonists are only sustained with continued use. Stopping these medications often leads to weight regain, as seen in studies like SURMOUNT-4. Over time, this yo-yo effect on body weight can increase the risk of metabolic complications, including higher cholesterol and blood pressure. 
• Cardiovascular risks: GLP-1 agonists have shown promising benefits for cardiovascular health, particularly in lowering heart attack and stroke risks for diabetes patients. However, these benefits have only been studied over a few years, and it remains to be seen whether these protective effects persist over the long term or if other cardiovascular risks emerge. 

The insulin analogy: a warning 

The story of insulin therapy offers a helpful analogy. Insulin dramatically extended the lives of patients with type 1 diabetes, but it also exposed them to new complications that hadn’t been anticipated. For instance, patients who lived longer on insulin therapy developed conditions like atherosclerosis and high blood pressure—conditions that could be linked to both the disease and the treatment itself. 

Similarly, while GLP-1 agonists effectively treat the symptoms of obesity and diabetes, they do not cure these diseases. The analogy suggests that long-term use of GLP-1 drugs could eventually lead to new, unexpected health problems as the body adjusts to continuous hormone manipulation. These risks may only become apparent after decades of use, much like the complications that arose with long-term insulin therapy. 

The known unknowns 

 Experts are cautious about the long-term use of GLP-1 drugs because we are still dealing with “known unknowns”—issues that we expect could arise but have not yet been thoroughly studied. These include: 

• Muscle loss: Rapid weight loss with GLP-1 agonists can result in muscle mass loss, which may impact long-term metabolic health and physical strength. Future treatments may need to address this muscle loss, just as new therapies have been developed to mitigate insulin-related complications. 
• Bone health: Some preliminary data suggest that prolonged use of GLP-1 agonists may impact bone density, potentially increasing the risk of fractures. 
• Fertility and pregnancy concerns: While early studies suggest GLP-1 agonists do not increase the risk of congenital disabilities, the long-term effects on offspring and future generations remain uncertain. Weight gain or loss during pregnancy could also influence the metabolic health of both the mother and the child. 

The future of GLP-1 agonists 

 As more people turn to GLP-1 agonists for weight loss and diabetes management, medical science may shift its focus toward drug therapy over diet and lifestyle changes, much as it did with insulin. While this pharmaceutical approach is practical, it may overshadow the importance of maintaining a healthy diet and active lifestyle in preventing the progression of obesity and diabetes. 

As new generations of GLP-1 agonists are developed, we may see efforts to refine these drugs to reduce side effects and long-term risks. But for now, patients considering lifelong use of GLP-1 drugs should remain cautious and continue to engage with their healthcare providers in discussions about the potential long-term impacts of these therapies. 

Embracing a good diet and lifestyle creates a positive feedback loop where your metabolic health improves, supporting weight maintenance and overall well-being. 

Conclusion 

While GLP-1 agonists like Wegovy and Mounjaro represent a significant breakthrough in treating obesity and diabetes, long-term use presents uncertainties. Patients should be mindful of the known side effects and the unknown risks that could arise after many years of continuous treatment. Just as insulin therapy brought about new medical challenges decades after its introduction, GLP-1 agonists could similarly reveal long-term effects that have yet to be fully understood. Therefore, it is crucial to balance the benefits of these medications with potential risks and continue to prioritise lifestyle changes in the management of obesity and diabetes. 

FAQs 

What Does Maintenance Therapy Include? 

Maintenance treatment with Mounjaro is licensed at doses of 5 mg, 10 mg, or 15 mg. If you are on a higher dose and still losing weight despite having reached a healthy, desirable BMI, it is essential to start lowering your dose. The goal is to reach a dose that balances your diet and lifestyle and your ability to maintain your weight without further weight loss. 

Can I Stop Abruptly With Mounjaro or Wegovy, or Do I Need to Reduce Slowly? 

In most cases, reducing the dosage slowly rather than abruptly stopping Mounjaro or Wegovy is recommended. Gradual dose reduction helps prevent sudden weight regain and allows your body to adjust to maintaining weight through diet and lifestyle alone. Abrupt discontinuation may increase the risk of rapid weight regain. However, you can stop abruptly without any risk to your health.