PharmD_Rodriguez 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.

pete_manc_UK 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.

Dr.PeteFamMed said:

I disagree that the ladder is purely tolerability.

Coming at Dr.PeteFamMed’s question from a different direction. The mechanism and the magnitude are separate questions. Agreeing that something happens says nothing about whether it happens enough to act on.

Following on from LindaRN_retired — and this may be the naive question:

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?

Reporting back.

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.