Dr.PeteFamMed 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.

pam_columbus 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…

PSA for titration users considering the 0.25mg starting dose: this dose is NOT intended for weight loss. It's a titration dose to let your body adjust. Don't be discouraged if you don't lose much in the first month.

The therapeutic dose for weight management starts at 1.7mg (semaglutide) or 5mg (tirzepatide). Be patient with the ramp-up.

labquiet_amy said:

I disagree that the ladder is purely tolerability.

There is a second half to this that has not been said yet. Whatever the answer turns out to be, the method for getting there is the same: state the assumption, do the arithmetic in public, and invite the correction. That is slower than asserting, and it is the only version that survives being wrong.

One thing that is still open after MikeNYC_runner’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.

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.