Resmetirom is the only approved MASH drug today. Survodutide just read out phase 3 obesity at 16.6%; LIVERAGE + LIVERAGE-Cirrhosis pending. Pemvidutide IMPACT-MASH starting phase 3 H2 2026. Why we hold on MASH-specific routing recommendations and what we'd need to see to start.
What actually shifted in the last 60 days: Foundayo (orforglipron) approved early under the National Priority Voucher, oral Wegovy 25mg shipping, FDA proposes excluding tirzepatide from 503B bulks, RFK pulled 14 peptides off Category 2, survodutide phase 3 obesity readout. Routing impact for each.
Eli Lilly's triple agonist (GLP-1 + GIP + glucagon) has TRIUMPH-1, TRIUMPH-2, and TRIUMPH-4 readouts in the public record. Weight reduction at 12mg lands above tirzepatide. Cardiovascular signal is being watched. FDA filing window now points at late 2026. What this changes in routing decisions today.
The dose-step decisions most people get wrong on tirzepatide. When to stay at 5mg, when to push to 10mg, what gastrointestinal side effects actually tell you, and the muscle-loss + protein math nobody mentions until it bites.
Retatrutide, orforglipron, CagriSema, survodutide, MariTide, pemvidutide. Where each one sits in phase 3, the readout window, the mechanism, and what each approval would shift for routing decisions today. Bleeding edge of the science, conservative on the rating.
What actually happens when you start tirzepatide. What is common, what is rare, what is serious, what to do about each.
Same drug class, different receptor profile. Here is the honest comparison, without the marketing gloss.