Dr.BariatricHTX 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…

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.

mona_PHX 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.

SarahChen_PharmD said:

I disagree that the ladder is purely tolerability.

There is a second half to this that has not been said yet. Order of operations matters more than any single choice here: establish a baseline, change one thing, wait long enough for it to express itself, then measure again under the same conditions.

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?

Closing the loop on my own question.

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.