Why dose increases are gradual

What titration means

Titration is the practice of starting a medicine at a low strength and increasing it in defined steps, with a minimum period at each one. Weight management medicines of this class are all prescribed that way, and the sequence of strengths is called a dose ladder.

The ladder is not a menu. It is the order in which strengths are worked through, and each rung has conditions attached to leaving it.

Why not start at an effective strength

Because the commonest side effects of these medicines are dose-related, and because tolerance to them builds with exposure. Starting at a strength somebody would eventually reach produces the nausea, vomiting and diarrhoea that the slow climb exists to avoid — often badly enough that the person stops treatment altogether.

So the first strength of every one of these medicines is an initiation strength. It is not intended as a treatment strength and nobody is meant to stay on it indefinitely. Its job is to let the body adjust.

The trade is deliberate: a slower start in exchange for a course somebody can actually stay on.

The minimum interval

Each step has a minimum time you must have spent at the one before it — conventionally four weeks for this class of medicine, though it is set per product by the medicine’s licence rather than by a general rule.

That interval is a hard stop. It is not a scheduling convention and a prescriber cannot waive it because things are going well. Our prescribing rules do not permit:

• skipping a step;
• increasing before the minimum interval at the current step has passed;
• exceeding the maximum strength the medicine is licensed at;
• increasing in a cycle where a severe side effect has been reported;
• increasing after a lapse in treatment, which is a restart rather than a continuation.

These are enforced rather than remembered. A rule that depends on a busy clinician recalling it on a Thursday afternoon is not a safety rule.

How the decision is actually made

At the review before each supply, a prescriber has your check-in in front of them: side effects and their severity, your weight over time rather than at one moment, doses missed, new medicines, new conditions. From that they decide to advance, hold, reduce, or stop and review.

Our system proposes one of those four and shows what it based the proposal on — the inputs and the rule that applied. A prescriber can accept it or override it, and an override is recorded with the reason. The proposal is a prompt to a clinician, not a decision: nothing is prescribed by software.

Some of what that means in practice is counterintuitive:

• Holding is a normal outcome. Several strengths of these medicines are licensed maintenance strengths, which people stay on for as long as treatment continues. Reaching one and stopping there is the ladder working, not stalling on it.
• Going down is a normal outcome too, and it is what should happen if side effects are making treatment hard to live with.
• How fast your weight is changing is one input, not the goal. A rapid change is itself a reason to reconsider rather than a reason to press on.

Why you cannot ask to move up

You can absolutely tell your prescriber how you are finding it, that side effects have settled, and that you would like to progress. That is useful and it is part of the check-in.

What you cannot do is choose. A strength is prescribed on clinical grounds, and a request is not one of them. This is the same reason the strengths on our treatments pages are published as a ladder with a price against each rung rather than as options to select: they are the order a course moves through, not a list to pick from.

When the ladder is corrected

Dose ladders are reference data held by this pharmacy and confirmed against each medicine’s current Summary of Product Characteristics by our superintendent pharmacist. Where guidance or a licence changes, the ladder is corrected — and a prescription already issued records which version of the rules it was issued under, so what applied on the day you were prescribed stays answerable later.

If something is wrong at your current strength

Do not manage a side effect by skipping doses or by halving them yourself. Tell us, so that a prescriber can decide — reducing, holding or stopping are all available and all normal. If you are unwell now, urgent help and out of hours says who to contact, and anything you suspect the medicine caused should be reported.