Dr.CardioMD said:

Four weeks is the pharmacokinetics, not caution.

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.

hannah_MT said:

Four dose steps in, holding each one the full four weeks, and I am trying to work out whether the interval is a pharmacological requirement or a…

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.

mike_nyc said:

I disagree that the ladder is purely tolerability.

Adding the part of the answer the thread has not reached. The distinction that resolves most of these threads is between what is true on average and what is true for one person. Both are real; they answer different questions and get quoted as if they were the same one.

A narrower follow-up, since the general answer is now clear:

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?

OP back with an update, since a thread like this is useless without one.

I held the step an extra three weeks instead of stepping back down, and it settled. Same dose, same everything, just more time — which is exactly what was suggested upthread.