Which weight-loss medications require titration?
Titration is the norm for almost every drug in or adjacent to the GLP-1 family, including semaglutide (the active compound in Ozempic and Wegovy), tirzepatide (Mounjaro), and liraglutide (Saxenda). Most non-GLP-1 weight-loss drugs, such as Contrave and Qsmyia also require titration.
What’s the point of dose titration?
Titration is considered to be a more individualized, patient-centered approach to dosing. At a high level, it’s used to optimize the benefits of a medication while minimizing the risk of side effects.
There’s variability in how people respond to GLP-1s, but it’s common to experience gastrointestinal side effects such as nausea, vomiting and diarrhea, and higher doses can intensify these side effects. Starting with a low dosage might help you avoid side effects altogether, or you might have milder side effects than you would without titration. Or you might even have side effects initially but feel OK at higher doses, Tietz says, because proper titration gives your body time to adapt to the medication.
Does everyone taking a GLP-1 start with the same dose?
Each drug has its own standardized starting dose and dosing schedule. For Wegovy injections (administered weekly), it’s standard to start at 0.25 milligrams and increase the dosage monthly for four months, until you reach the maximum dose of 2.4 milligrams. Mounjaro, when prescribed off-label for weight loss, also has a four-month dose titration; the typical starting dosage is 2.5 milligrams, increased monthly until you reach the maximum dose of 15 milligrams.
So, most patients taking the same medication receive identical instructions at the outset. But there are instances where it might be necessary to deviate from the planned dosing schedule, such as if a patient develops severe side effects and needs more time to adjust to a dose, or needs to pause treatment due to a medical event (like an operation).
“GLP-1 treatment is very personalized,” says Tietz. “Everyone starts with the same dose titration plan, but then things can change throughout the process based on feedback and how treatment works. Patients need to be open and understand that not everyone’s journey is going to be the same once treatment begins.”
Does everyone reach the maximum dose?
Nope. Some people taking weight-loss drugs reach the maximum dose (sometimes called the maximum target dose), but others stop up-titrating sooner. This might happen if you’re having success at a certain dose (i.e., you’re losing weight) and then, when you move up to the next dose, the side effects of the medication become hard to tolerate.
“If you haven’t reached the maximum yet — maybe you’re at the second-to-last dose increase — and the first week you do it, your body doesn’t quite handle that new dose,” Tietz explains, “then your doctor might take you back to the last dose you were doing well on.”
The dose you eventually stay on is your maintenance dose (sometimes called the maintenance target dose). People taking the same medication often end up on different maintenance doses. The goal for every patient is to identify the minimum dose required to reach maximum effectiveness. Patients shouldn’t be discouraged if they don’t end up taking the maximum dose, Tietz notes. It doesn’t mean they won’t achieve their desired weight loss.
If you’re tolerating a GLP-1 well, can you take a higher dose earlier than planned?
This isn’t a good idea, Tietz warns: “Titration is a long, slow process, and sometimes, once patients start seeing benefits, they’ll say, Forget this, I’m jumping all the way up to where I’m supposed to be. But going too quickly doesn’t mean you’ll have better results faster, and it can cause problems.”
Accelerating the titration process can worsen side effects and, as a result, increase the likelihood of discontinuing treatment, Tietz says. “A lot more people will have therapy failure when they go too fast, because it’s just too rough to handle.”
Some patients also decide to go above the maximum dose. “They take matters into their own hands, because they think more medication equals more weight loss,” Tietz says.
If a patient exceeds the maximum dose and reports it to their doctor, Tietz says the doctor might refer them to the ER. Why? They might have side effects too severe to manage at home, such as persistent vomiting or a total lack of appetite. This can become dangerous if a patient experiences a large drop in blood sugar over time.
What happens if you accidentally mess up your dosing schedule, and take a higher dose too soon?
“In most cases,” says Tietz, “a doctor would recommend dropping back to the lower dose — but it depends on how long a patient has been taking the higher dose.”
There’s a lot of individual variation in how patients respond to dosage increases. If you up-titrate and have a negative reaction, you should always tell your doctor. “Sometimes patients avoid saying things about side effects because they want to have optimal weight loss and are worried they won’t be allowed to continue treatment,” Tietz says. “But providers are familiar with these medications and have seen a lot of patients. They know what the next best step is.”