Armistice Capital Among Madrigal Holders as Rezdiffra Tops $1 Billion in MASH Sales

20th Jul 2026
Few recent drug launches have scaled as quickly as Rezdiffra, and the company behind it, Madrigal Pharmaceuticals, has become a case study in what a first-in-disease approval can do for a single-product biotech. Madrigal built its business around resmetirom, sold as Rezdiffra, the first therapy cleared by the FDA for metabolic dysfunction-associated steatohepatitis, a progressive liver disease long without an approved treatment. The stock is among Armistice Capital's larger disclosed positions in its most recent 13F filing, a stake also reflected in the fund's institutional portfolio, and Madrigal counts numerous institutional investors among its shareholders. A First-in-Disease Launch When the FDA granted Rezdiffra accelerated approval in March 2024 for adults with noncirrhotic MASH and moderate-to-advanced liver fibrosis, it validated a mechanism, thyroid hormone receptor-beta activation in the liver, that the field had pursued for years. MASH, until recently referred to as NASH, is a form of fatty liver disease that inflames and scars the liver and can progress to cirrhosis; it affects millions of adults in the United States, and for years the only interventions were diet, exercise, and management of related conditions. What followed the approval was an unusually fast commercial ramp. Trailing-12-month net sales have moved above $1.1 billion, and the product carries a gross margin near 94%. Compounding Growth The first quarter of 2026 showed the trajectory continuing. Madrigal reported $311.3 million in revenue, up 127% year over year, and counted more than 42,250 active patients on Rezdiffra at the end of March. The company posted a net loss of $3.25 per share, narrower than the roughly $4.19 analysts had expected, as commercial revenue outpaced the spending required to support the launch. The patient count matters as much as the revenue line: it signals that uptake is continuing well beyond the initial launch phase. That expansion is happening as the competitive picture shifts. Makers of GLP-1 medicines, developed for diabetes and obesity, have reported liver benefits in MASH studies, raising the prospect of eventual competition or combination use. But for now, Rezdiffra remains the only therapy approved specifically for the disease, and Madrigal's head start and proven performance could entrench prescribing habits before rivals arrive. Extending the Franchise Madrigal is not standing still on a single formulation. In late May, at the European Association for the Study of the Liver's EASL Congress 2026 in Barcelona, the company presented data on Rezdiffra's effect on markers of cardiovascular and portal-hypertension risk, along with late-breaking results in compensated MASH cirrhosis, a more advanced stage of the disease for which the drug is not yet approved. An outcomes trial in that population is ongoing. The company is also reaching into new modalities. In early July, Suzhou Ribo Life Science reached the first candidate-nomination milestone in a small interfering RNA partnership with Madrigal aimed at MASH, triggering the start of IND-enabling studies. The collaboration points toward a next generation of liver therapeutics beyond the oral small molecule that defines the company today. The compensated-cirrhosis question is the larger prize. Patients whose disease has advanced to that stage face the highest risk of liver-related complications, and a label extension would enlarge the treatable population well beyond the fibrosis stages Rezdiffra covers today. The outcomes trial now running will take time to read out, but the late-breaking data presented in Barcelona is the kind of evidence Madrigal would need to make the case. Scale brings its own demands. Supporting tens of thousands of patients requires a commercial organization, distribution, and patient-support programs far larger than the ones a development-stage company maintains, and that infrastructure has been built out as the launch runs. The siRNA collaboration and the cirrhosis program could signal that management is spending some of the revenue the drug now generates on the next phase of the business rather than banking it. The Shareholder Base Madrigal's register reflects the interest a commercial-stage rare-disease company tends to attract. Specialist funds such as Baker Bros. Advisors, RTW Investments, and Avoro Capital Advisors hold large stakes, as do index managers Vanguard and BlackRock and hedge funds including Armistice Capital. What happens next turns on Rezdiffra's reach, the cirrhosis outcomes trial, and the siRNA program. Turning a first approval into blockbuster-scale revenue within two years is something few single-product biotechs manage. Sustaining it is the harder test.