The standard schedule
Semaglutide for weight management escalates across five steps, with each dose held for four weeks before moving up.
- Weeks 1 to 4: 0.25 mg weekly. A starting dose, not a therapeutic one.
- Weeks 5 to 8: 0.5 mg weekly.
- Weeks 9 to 12: 1.0 mg weekly.
- Weeks 13 to 16: 1.7 mg weekly.
- Week 17 onward: 2.4 mg weekly, the maintenance dose.
Why four weeks between steps
Semaglutide has a half-life of about a week, so it takes roughly four to five weeks for blood levels to stabilise after any change. Moving up sooner means stacking a new increase on top of levels that are still climbing.
That is the pharmacology behind the schedule, and it is why escalating faster reliably produces a worse experience without producing faster results.
Maintenance does not have to be the maximum
The labelling anticipates that some people will not tolerate 2.4 mg, and allows 1.7 mg as a maintenance dose in that case.
Beyond what the label permits, plenty of people get the result they want at 1.0 mg or 1.7 mg and stay there. The schedule is a ceiling, not a target, and there is no clinical prize for reaching the top of it.
Missed doses
The labelled rule is straightforward. If you miss a dose and your next scheduled dose is more than two days away, take the missed one as soon as you remember. If the next scheduled dose is less than two days away, skip the missed one and carry on as normal.
If you miss more than two consecutive weekly doses, do not simply resume where you left off. Speak to your prescriber, because restarting at a lower dose is often appropriate after a gap that long.
Changing your injection day is allowed as long as at least two days have passed since the last dose.
What changes the right dose for you
- Tolerability, which is by far the biggest factor and is not predictable in advance.
- Whether you have type 2 diabetes, which affects both the expected response and what else you are taking.
- Insulin or sulfonylurea use, which usually needs adjusting downward to manage hypoglycaemia risk rather than adjusting the semaglutide.
- Pregnancy or planning one, which is a reason to stop rather than adjust. The labelled advice is to discontinue at least two months before a planned pregnancy.
- The labelling does not require dose adjustment for kidney or liver impairment, but both warrant a more careful conversation, particularly given the dehydration route to kidney injury.
Ozempic and Wegovy are dosed differently
This catches people out constantly. Both are semaglutide, but the weight-management product goes to 2.4 mg weekly while the type 2 diabetes product tops out at 2.0 mg, with a different escalation.
If you are switching between them, or if your prescription changes because of what insurance will cover, confirm the schedule rather than assuming it carries across.
Compounded dosing is a different risk profile
Brand pens deliver a fixed dose. Compounded semaglutide usually arrives as a multi-dose vial at a concentration the pharmacy chose, and you draw the dose yourself.
That is where the serious dosing errors happen, and they happen by factors of ten. Insulin syringes are marked in units, not milligrams. Your prescription is in milligrams. Your vial has a concentration in milligrams per millilitre. You cannot draw correctly without all three numbers and the conversion between them.
The FDA has issued alerts about dosing errors with compounded semaglutide, including cases where people administered many times the intended dose and required hospital treatment. If you are using a vial, work the arithmetic on paper the first time at any new concentration, and check it against what your prescriber told you.
Safety rules that do not change whatever your dose
- Never double up to make up for a missed dose.
- Never increase the dose on your own initiative because progress feels slow.
- Never use a product that has frozen, whatever it looks like afterwards.
- Tell any surgical or endoscopy team you are on it, well before the procedure.
Sources
- Wegovy (semaglutide) injection, prescribing information. Novo Nordisk.
- Ozempic (semaglutide) injection, prescribing information. Novo Nordisk.
- Wilding JPH, et al. Once-Weekly Semaglutide in Adults with Overweight or Obesity (STEP 1). N Engl J Med. 2021;384(11):989-1002.
- US Food and Drug Administration. FDA alerts health care providers, compounders and patients of dosing errors associated with compounded injectable semaglutide products.
- American Society of Anesthesiologists. Consensus-based guidance on preoperative management of patients on glucagon-like peptide-1 receptor agonists.