Explainer

Titration, properly explained

When to step up, when to hold, when to go back down, and why restarting after a gap is the one genuinely dangerous mistake.

Calm abstract illustration of a small vial and syringe

Updated 2026-09-18

Titration exists because these drugs slow stomach emptying substantially, and a body given a therapeutic dose on day one responds badly enough that most people would stop within a fortnight.

The principle is simple: start low, go up slowly, and stop where it works. The complication is that "slowly" is a clinical judgement rather than a fixed schedule, and a lot of programmes run it as a calendar instead — which is how people end up at a dose their body was not ready for.

What is happening pharmacologically

The dose ladder is a tolerance-building protocol, not a marketing device. Each step gives the gut time to adapt before the next increase, which is why skipping rungs produces nausea out of proportion to the dose. It is also why tolerance fades on a break: restart where you left off after several weeks away and you are, physiologically, starting high.

Why you cannot just start at the effective dose

Because your gut needs time to adapt. These drugs slow stomach emptying substantially, and going straight to a therapeutic dose produces nausea and vomiting severe enough that most people would stop within a fortnight. The starting dose buys tolerance, not results — which is why judging the medication on month one is the commonest mistake we see.

The two ladders

Step	Tirzepatide	Semaglutide
1	2.5 mg — acclimatisation	0.25 mg — acclimatisation
2	5 mg — first therapeutic dose	0.5 mg
3	7.5 mg	1 mg — therapeutic
4	10 mg — trial dose (19.5% avg)	1.7 mg
5	12.5 mg	2.4 mg — maintenance (14.9% avg)
6	15 mg — maximum (20.9% avg)	—

Each step is roughly four weeks. That is a default, not a rule, and the trial averages are averages rather than targets.

When to hold

Holding at your current dose for an extra month is a normal clinical decision, not a failure. Hold if side effects have not settled, if you are still losing weight steadily at this dose, or if you simply do not feel ready. A programme that pushes you up regardless is running a schedule rather than treating you.

Important. Holding should be free. On a programme that prices by dose, staying put can feel like paying the same for less — which is a financial pressure on a clinical decision. 6 providers in our table hold one price across the entire ladder, which removes that pressure entirely. See our price tables.

When to step back down

Going down a rung is a legitimate move and an under-used one. Reasons to consider it: side effects that have not settled after several weeks at a dose, appetite suppression so complete that you cannot eat enough protein, or having reached your goal and wanting a maintenance dose rather than a maximum one. Discuss it with your prescriber rather than simply taking less than you were prescribed.

What a good programme does

Reviews each increase against how you are actually doing, rather than applying it on a timer.
Makes holding easy to request and does not charge you more for it.
Answers within days when a dose goes badly, not at the next scheduled appointment.
Asks before escalating rather than shipping the next dose automatically.
Has a clear position on what happens if you miss weeks.

Questions worth asking before you start

How are dose increases decided — by a clinician reviewing my progress, or on a schedule?
What happens to my price when my dose goes up?
How do I request to stay at a dose for longer, and does that cost me anything?
Who do I contact if an increase goes badly, and how quickly do they respond?
What is your protocol if I miss two or three weeks?