GLP-1 Dosing & Titration — How the Ladders Work

Why doses start tiny and climb slowly, the official Wegovy and Zepbound schedules, what "stay at the lowest effective dose" means, and how missed doses and switches are handled.

Why titration exists at all GLP-1 doses start at a fraction of the target and climb over months for one reason: the gut adapts to slowed emptying gradually. Jumping straight to a therapeutic dose produces the nausea horror stories; climbing slowly produces the boring success stories. Titration is not bureaucracy — it is the side-effect management strategy. Three principles govern every ladder: 1. Time at each step matters. Standard schedules hold each dose at least 4 weeks. Extending a step is always acceptable; rushing one rarely is. 2. The target is response, not the top dose. If you are losing steadily at a middle dose with no side effects, there is no obligation to escalate. “Lowest effective dose” is mainstream practice — and cheaper. 3. Down is allowed. Dropping back one step after a rough increase, stabilizing, then re-trying is standard, not failure. ## The official brand ladders Wegovy (semaglutide): 0.25 → 0.5 → 1.0 → 1.7 → 2.4 mg, four weeks per step. 1.7 mg is a recognized maintenance dose for patients who do not tolerate 2.4. Zepbound (tirzepatide): 2.5 → 5 mg after four weeks, then optional 2.5 mg increases every four or more weeks to 7.5, 10, 12.5, or 15 mg. All of 5/10/15 are approved maintenance doses — many patients stay at 5 or 7.5 long-term. Saxenda (liraglutide): 0.6 mg daily, +0.6 weekly to 3.0 mg daily. ## Compounded ladders — why the numbers look different Compounded protocols often use different increments than the pens (one common compounded semaglutide pattern climbs roughly 0.3 → 0.6 → 0.9 → 1.5–2.2 mg weekly) because vial-and-syringe or custom-filled dosing isn’t locked to factory pen sizes. Finer steps are the legitimate advantage of compounding; they allow slower climbs for sensitive patients. Sublingual ladders use entirely different numbers again (e.g., 1–6 mg for semaglutide RDTs, 3–7 mg for tirzepatide RDTs) because under-the-tongue absorption is lower — never map sublingual milligrams onto injection milligrams. ## Missed doses (weekly injectables) - ≤ 5 days late (Wegovy) / within 4 days (Zepbound): take it when remembered, then resume your usual day. - Longer: skip, take the next scheduled dose. Never double. - Missed ≥ 2–4 weeks: call your prescriber — restarting at a lower step is often recommended, since gut tolerance fades fast off the drug. ## Switching medications Switching (semaglutide ↔ tirzepatide, brand ↔ compounded) is common and should be conservative: stop one, start the other at a non-equivalent, deliberately modest step chosen by the prescriber based on how long you have been off and how you tolerated the first drug. There is no official conversion chart between molecules — anyone quoting an exact “equivalent dose” between semaglutide and tirzepatide is improvising. ## Injection mechanics in 30 seconds Subcutaneous, once weekly, any time of day, with or without food., front of thigh, back of upper arm. Same day each week, but the day can be shifted as long as doses stay ≥ 48 hours apart. Pens store in the fridge; most tolerate limited room-temperature periods (check the specific label). Travel with pens in carry-on, never checked baggage. ## Microdosing — the deliberate exception Some maintenance and sensitivity protocols intentionally run below standard ladders. That practice has its own logic and its own guide: GLP-1 microdosing explained.