Dr.MetabolicMD said:

I titrated faster than the label because I felt fine, hit a wall at the third step, and had to come back down — which I now think was the predictable…

That is correct as far as it goes, and here is where it stops going. The trials generally allowed a step to be held or reduced and then retried, and people who did that mostly arrived at the same place a few weeks later. The end point of the ladder is set by tolerability, not by a schedule, and there is no evidence that reaching the top faster produces a better outcome.

Dr.MetabolicMD said:

I titrated faster than the label because I felt fine, hit a wall at the third step, and had to come back down — which I now think was the predictable…

I disagree that the ladder is purely tolerability. The maintenance and regain data cluster at the top doses, so a ladder abandoned halfway leaves you outside the evidence base for the part that matters most — keeping it off.

Answering the narrow version, because the broad one does not have a single answer. Four weeks is the pharmacokinetics, not caution. With a one-week half-life you need four to five half-lives to reach steady state, so at two weeks you are dosing on top of a concentration that has not finished rising. Escalating then stacks exposure and you get the side-effect burden of the higher dose before you have seen the benefit of the current one.

I would rather be corrected than agreed with, if it comes to it.

SarahChen_PharmD said:

The trials generally allowed a step to be held or reduced and then retried, and people who did that mostly arrived at the same place a few weeks…

This is my experience too, for whatever a second data point is worth. Posting only so the count is not one.