SarahChen_PharmD 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.

fiona_VT 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.

mike_nyc said:

I disagree that the ladder is purely tolerability.

There is a second half to this that has not been said yet. The mechanism and the magnitude are separate questions. Agreeing that something happens says nothing about whether it happens enough to act on.

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

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

Why the interval is four weeks rather than two, and whether a slower ladder gets to the same place?

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.