PharmacoVig_BOS 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.

Correct me if the detail matters more than I have assumed.

jason_paloalto 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. Worth answering the question that was asked rather than the one behind it. The narrow version usually has an answer; the broad version usually does not, and answering the broad one is how a thread stops being useful.

One thing that is still open after SaraMom3’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?

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

Update — I came back down one step, held for a month, then went up again and it was uneventful the second time. Same ladder, slower.