2026 Obesity Medication Guidelines: ACP, Obesity Societies and VA/DoD Compared

Three major US guidelines on weight-loss medicines came out between late 2025 and mid-2026, and they agree on the main point. The American College of Physicians (ACP) now calls semaglutide and tirzepatide first-line treatments for adults with obesity.^[1] The Obesity Society, Obesity Medicine Association and Obesity Action Coalition give both a strong recommendation, along with naltrexone-bupropion and setmelanotide.^[4] The VA and Department of Defense guideline says you don't have to finish a lifestyle program before starting medication.^[5] Two of the three explicitly support staying on an effective medicine to keep the weight off.^[4][5] Here is what each guideline recommends, where they differ, and what it means if you are trying to get a prescription or coverage.

The short answer

• Semaglutide and tirzepatide are first choice. The ACP ranks them first-line for adults with a BMI of 30 or more, and for adults with a BMI of 27–30 who also have type 2 diabetes, high cholesterol, high blood pressure, sleep apnea or heart disease.^[1]
• Older drugs are still options, ranked lower. For BMI 30 or more, the ACP lists phentermine-topiramate second, liraglutide third and naltrexone-bupropion fourth, all on low-certainty evidence.^[1]
• Long-term use is the default. The TOS/OMA/OAC statement gives a strong recommendation to continuing medication during weight maintenance, and the VA/DoD guideline “discourages discontinuation of effective medications to prevent weight regain.”^[4][5]
• You don't have to “fail” diet first. The VA/DoD found “no requirement to complete CLI before initiating additional treatments,” where CLI means a comprehensive lifestyle intervention.^[5]

ACP living guideline (April 2026)

The ACP guideline is written for internists and other clinicians caring for adults in outpatient settings.^[1] It is a “living” guideline, meaning it will be updated as new trials are published. Both recommendations are conditional (the ACP “suggests” rather than “recommends”), and both pair medication with lifestyle changes.^[1]

The ACP also lists what clinicians and patients should discuss before starting or switching: “benefits, harms, costs, access and availability, clinical comorbidities, weight loss goals, life expectancy, values and preferences, and contraindications and warnings.” It gives examples: monthly pregnancy tests with phentermine-topiramate, its contraindication in people with cardiovascular disease, and suicidal ideation warnings with naltrexone-bupropion.^[1]

The evidence behind the ranking

The ACP based its ranking on a living systematic review and network meta-analysis of 69 randomized trials with 112,511 participants. Nearly every drug beat placebo or lifestyle change alone for weight loss, but with more people stopping because of side effects. “Semaglutide probably reduced mortality and major adverse cardiovascular events (MACE), and both semaglutide and tirzepatide led to the greatest weight loss.” The reviewers noted that direct head-to-head trials were limited.^[2] The review searched trials through October 2025 and included drugs that were still investigational at the time, such as orforglipron (FDA-approved as Foundayo on April 1, 2026) and retatrutide (still investigational), but the recommendations cover only semaglutide, tirzepatide, phentermine-topiramate, liraglutide and naltrexone-bupropion.^[1][2]

What the ACP found on cost

A companion review looked at US cost-effectiveness studies that were not funded by industry. In the moderate-certainty studies, compared with lifestyle change alone, tirzepatide and phentermine-topiramate were “high value” (under $100,000 per quality-adjusted life-year) and liraglutide was “low value.” Semaglutide was low value compared with naltrexone-bupropion and phentermine-topiramate, and high value compared with liraglutide. The authors cautioned that the evidence “is hampered by poor-quality studies, limiting the ability to draw conclusions,” and that all the studies were model-based.^[3] For what these drugs actually cost patients today, see our GLP-1 price transparency index.

TOS, OMA and OAC joint guidance (2026)

The Obesity Society, the Obesity Medicine Association and the Obesity Action Coalition, a patient advocacy group, convened a panel that included patient representatives. Using the same GRADE method as the ACP, they issued:^[4]

• Strong recommendations for bupropion-naltrexone, semaglutide, tirzepatide and setmelanotide, all with moderate-certainty evidence.
• Conditional recommendations for other FDA-approved agents (orlistat, phentermine, phentermine-topiramate and liraglutide), and for treating specific obesity complications: sleep apnea, heart failure with preserved ejection fraction, fatty liver disease (MASLD/MASH), osteoarthritis, cardiovascular events and type 2 diabetes.
• A strong recommendation for continuing obesity medications during weight maintenance.

The panel called obesity “a chronic, often progressive, disease requiring comprehensive, long-term, and person-centered care,” and said effective medications “remain underutilized due to systemic barriers” including cost and coverage.^[4]

VA and DoD guideline (2025 update)

The 2025 VA/DoD guideline for veterans and service members covers screening as well as treatment. It suggests routine screening for everyone with a BMI of 25 or more (23 or more for Asian adults), together with waist size. It “strongly recommends comprehensive lifestyle intervention (CLI) as the foundation of care,” but found “insufficient evidence to recommend for or against delaying pharmacotherapy relative to CLI and no requirement to complete CLI before initiating additional treatments.” It “discourages discontinuation of effective medications to prevent weight regain.”^[5]

Where the guidelines differ

The biggest difference is naltrexone-bupropion (Contrave). The obesity societies give it a strong recommendation, while the ACP puts it last on low-certainty evidence. The ACP is also more cautious overall: its recommendations are conditional, where the obesity societies made several strong ones.^[1][4] For a closer look at the older drugs, see phentermine-topiramate (Qsymia) and Contrave side effects.

What this means for you

• If your insurer requires “step therapy” (trying an older drug first), the ACP's first-line ranking of semaglutide and tirzepatide is a useful document to bring to an appeal. It does not change the policy by itself.^[1]
• If you are told to diet for six months before medication, the VA/DoD guideline found no requirement to complete a lifestyle program first.^[5]
• If you are thinking about stopping once you reach a goal, two of the three guidelines support staying on an effective medicine. See life after a GLP-1: maintenance options and what happens when you stop.^[4][5]
• If you are choosing between the two first-line drugs, the guidelines don't pick one. See tirzepatide vs semaglutide head to head and Zepbound vs Wegovy cost.

Bottom line

The 2025–2026 US guidelines now line up behind semaglutide and tirzepatide as the preferred weight-loss medicines for most adults who qualify, with older drugs as alternatives when cost, access or side effects rule them out. They also treat obesity as a long-term condition. Two of the three explicitly back staying on medication that works, and the VA/DoD drops the idea that you must complete a diet program before medication. None of this guarantees coverage, but it gives patients and prescribers a clear, citable standard of care.