Maintenance transition checklist: questions for your prescriber, framed by SURMOUNT-4 and STEP 4

At some point the question changes from "is it working" to "what now". Goal reached, or cost, or coverage, or side effects, or simply time. The worst way to have that conversation is from anecdote. Two randomised trials measured exactly the situation, and their numbers are printed at the top of this sheet so that you and your prescriber start from the same page.

What the trials did

SURMOUNT-4 (Aronne and colleagues, JAMA 2024, PubMed 38078870) gave 783 adults with obesity or overweight without diabetes open-label tirzepatide at 10 or 15 mg for 36 weeks. The 670 who completed that lead-in had lost a mean of 20.9 percent of their weight. They were then randomised to continue tirzepatide or switch to placebo for 52 weeks. From week 36 to week 88, the continuing group lost a further 5.5 percent; the placebo group regained 14.0 percent. At week 88, 89.5 percent of those continuing had kept at least 80 percent of their lead-in loss, against 16.6 percent on placebo. Over the whole 88 weeks the totals were 25.3 percent lost with tirzepatide and 9.9 percent with placebo. Adverse events were mostly mild to moderate gastrointestinal ones and were more common with tirzepatide.

STEP 4 (Rubino and colleagues, JAMA 2021, PubMed 33755728) ran 902 adults with obesity or overweight without diabetes through a 20-week run-in on semaglutide titrated to 2.4 mg weekly. The 803 who reached that dose had lost a mean of 10.6 percent. They were randomised two to one to continue semaglutide or switch to placebo for 48 weeks, both with lifestyle support. From week 20 to week 68, the continuing group lost a further 7.9 percent; the placebo group regained 6.9 percent. Waist circumference, systolic blood pressure and physical-functioning scores also favoured continuation. Gastrointestinal events were reported by 49.1 percent of those continuing semaglutide and 26.1 percent on placebo, with similar low discontinuation rates for adverse events in both groups.

What they did not do

Neither trial tested a lower dose, a longer interval between doses, or a gradual taper. Neither included people with diabetes. Both report means, and a mean hides the people who kept most of their loss without the drug as well as the people who regained more than average. The sheet says this in a printed line, because it is the part that gets forgotten when the headline numbers are quoted.

The questions

Six for the prescriber, with answer lines: what they expect for you if you continue and if you stop, given these trials; which options are actually on the table and what evidence each has; how a change would be monitored and what would bring you back in; what nutrition and resistance-training plan should be in place first; if cost or coverage is the driver, what the realistic alternatives cost; and what the plan is for restarting if it comes to that. The maintenance planner on the weight loss site applies the trial percentages to your own weight as arithmetic, if you want to see the figures at your scale before the visit.

What to bring

The last sixteen weeks of the weight and waist tracker, the dose log and side-effect diary, your current monthly cost and coverage status, and your own goals for the next year written in the lines at the bottom. The FormBlends cost report is the quickest way to put a current number on the cost line.

Nothing on this sheet recommends continuing, reducing or stopping. That decision is yours and your prescriber's, and the sheet's only job is to make sure it is an informed one.