What the first months tend to look like
Described by titration phase rather than by calendar week, because what matters is where you are in the escalation, not how long you have been on it.
- Starting dose, first four weeks. Usually the quietest phase. Early satiety appears before anything unpleasant does. The starting dose is not a therapeutic dose for weight and is not meant to be.
- The days after any increase. The hard window is generally two to four days after the step up rather than injection day itself, because these drugs take days to climb toward a new steady state. The first week at a new dose is reliably worse than the third.
- Months two to four. The gastrointestinal effects attenuate faster than the appetite effects do. This is the adaptation that titration exists to allow, and it is why a dose that floored you at first can become unremarkable.
Titration decisions
The schedule is a ceiling, not a timetable. Three decisions are available at every step, and only one of them gets talked about.
- Going up. Only where the current dose is tolerated and more effect is actually wanted.
- Holding. Entirely normal, clinically ordinary, and the right answer for a substantial number of people. Plenty of people get the result they want at an intermediate dose and stay there indefinitely.
- Going back down. Also available. A dose you cannot tolerate is not a dose you have to push through.
- Moving up faster than four-week intervals is the most common avoidable cause of a bad first few months.
When to call your prescriber
These are not wait-and-see items.
- Severe, persistent abdominal pain, particularly radiating through to the back. This needs assessment for pancreatitis rather than time.
- Pain under the right ribs, especially after fatty meals, which can be gallbladder.
- Vomiting or diarrhoea that stops you keeping fluids down. Dehydration on these drugs is the route to acute kidney injury.
- Hypoglycaemia symptoms, if you also take insulin or a sulfonylurea.
- Any new or worsening visual change, if you have diabetic retinopathy.
- A lump or swelling in the neck, hoarseness, or difficulty swallowing.
Before any surgery or procedure with sedation
Tell the team you are on a GLP-1, well in advance. Retained stomach contents raise the risk of aspiration under general anaesthesia, and anaesthetic guidance on this has changed in recent years. This is easily the most commonly missed item on this page.
Muscle, protein and plateaus
- Some of what comes off is lean mass. Resistance training and adequate protein are the two mitigations with real support behind them.
- Plateaus are expected rather than a sign of failure. Weight loss on these drugs is not linear and the trial curves flatten too.
- A plateau is not automatically a reason to increase the dose. Whether it is depends on what you are treating and what your clinician thinks.
If you are thinking about stopping
Stopping is followed by substantial regain in every withdrawal study across this class. That is not an argument against stopping, which is a legitimate decision for all sorts of reasons. It is an argument for making it a planned conversation with your prescriber rather than a quiet lapse, so that whatever comes next is deliberate.