VendorMark 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.

HealthEcon_DC said:

Four dose steps in, holding each one the full four weeks, and I am trying to work out whether the interval is a pharmacological requirement or a…

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.

InsuranceTom said:

I disagree that the ladder is purely tolerability.

Adding the part of the answer the thread has not reached. If two explanations both fit, the useful question is which one predicts something the other does not. That is answerable; arguing about which sounds more plausible is not.

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

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.