Dr.SleepRoch said:

A step that is uncomfortable at week two is frequently comfortable at week six with no change in dose, because the gastric-emptying component…

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.

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

tammy_FL 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…

Dose escalation anxiety for titration: I was terrified to move from 0.5mg to 1.0mg based on horror stories in this forum. But my actual experience? Slightly more appetite suppression, zero additional side effects.

Remember that the people posting about terrible side effects are a biased sample. Most people titrate up without drama — they just don't post about it because it's uneventful.

RetaRick_CA said:

I disagree that the ladder is purely tolerability.

Adding the part of the answer the thread has not reached. It helps to say which part of this you are uncertain about. A precise question gets a precise answer; a general one gets everybody’s favourite anecdote.

One thing that is still open after rick_sfbay’s answer:

What the trials actually did with participants who could not tolerate a step, because that is the situation I am in and the protocol summaries skip it?

Closing the loop on my own question.

Closing this out: I held the step for six weeks rather than four and it settled without a dose change. The interval was the answer, not the dose.