Dose escalation protocols: standard vs slow vs aggressive

Standard escalation is 4-week intervals. Some patients need slower, some can go faster. Decision criteria and protocols.

Standard escalation (default)

Semaglutide: 0.25 → 0.5 → 1.0 → 1.7 → 2.4 mg at 4-week intervals.

Tirzepatide: 2.5 → 5 → 7.5 → 10 → 12.5 → 15 mg at 4-week intervals.

Most patients fit this protocol. ~70% reach maintenance dose by week 20.

Slow escalation

Hold each dose 8 weeks instead of 4. Indications:

• Severe GI symptoms at standard pace
• History of severe GERD or gastroparesis
• Elderly or frail patients
• Concurrent medication adjustments needed

Slow escalation reaches maintenance ~week 40 instead of week 20. Total weight loss outcome typically similar.

Aggressive escalation (avoid)

Sometimes patients want to "speed up" by escalating faster than 4 weeks. This is not recommended. The 4-week interval allows pharmacokinetic steady-state development and side effect adaptation. Faster escalation produces more severe GI symptoms without faster weight loss benefit.

Hold and resume

If side effects warrant pausing at a given dose: hold 4 additional weeks at current dose; do not drop down unless severe. Most patients can resume escalation after the extended hold.

Sub-maximum maintenance

Not every patient needs maximum dose. Some patients respond well at 1.0 mg sema or 7.5 mg tirz. If response is satisfactory and side effects are acceptable, holding at sub-maximum is appropriate.