semaglutide titration depends on the formulation. Wegovy (obesity, 2.4 mg target, with a 7.2 mg high-dose option approved march 2026) is a five-step ladder over twenty weeks, with an optional sixth step at 7.2 mg. Ozempic (type 2 diabetes, 2.0 mg max) is a three-to-four-step ladder. both start at 0.25 mg subcutaneous weekly. both use four weeks per step as the FDA-approved minimum.
this brief covers the FDA-approved titration schedule for both Wegovy (approved june 2021, with the Wegovy HD 7.2 mg high-dose label added march 2026) and Ozempic (approved december 2017). same molecule, different label, different target dose, different side-effect ceiling. Rybelsus (oral semaglutide for T2D) is noted at the end.
the FDA-approved obesity ladder.
the FDA-approved type-2-diabetes ladder.
what STEP 1 reported.
GI side effects are dose-dependent and pronounced at every step. STEP 1 (Wegovy's pivotal obesity trial, n=1,961) reported the following incidence at the 2.4 mg dose over 68 weeks:
the escalation logic: the trials held the current dose rather than stepping up when significant nausea, vomiting, or diarrhea persisted. STEP 1 protocol allowed slower titration when symptoms persisted; prescribers often mirror this.
what the FDA label says.
Wegovy/Ozempic FDA prescribing information: the label directs that a dose more than 5 days late be skipped, with the regular weekly schedule resumed at the next dose. the 5-day window is longer than tirzepatide's 4-day rule because semaglutide's half-life is longer (~7 days vs tirzepatide's ~5 days).
for a missed dose inside the 5-day window, the label directs administration as soon as the patient remembers, then continuing the weekly schedule. a missed dose does not restart titration. (this reports the FDA label, a prescriber reference, not self-administration guidance.)
the case for holding the current dose:
nausea or vomiting persisting beyond two weeks at the dose. semaglutide's GI side-effect curve is steeper than tirzepatide's at comparable steps. in the trials, holding before adding dose was standard.
the goal is met at a lower dose. STEP 4 showed that 1.0 mg sustains roughly 10% loss; 1.7 mg sustains 13-14%; 2.4 mg pushes to 15%. each step trades modest additional efficacy for more side effects. many patients hold at 1.0-1.7 mg and stay there.
side effects affect daily function. the STEP protocol allowed dose hold or step-down to preserve adherence. discontinuation rates climb above 1.7 mg.
Wegovy vs Ozempic: where patients typically land.
Ozempic (T2D): escalation is HbA1c-driven. most patients reach target glycemic control at 0.5-1.0 mg and stay there. doctors don't routinely push to 2.0 mg without clinical reason.
Wegovy (obesity): escalation aims for 2.4 mg target. STEP data shows clear dose-response in weight loss. 2.4 mg outperforms 1.7 mg by roughly 2-3 percentage points of total body weight reduction. some patients land at 1.7 mg if side effects persist.
Rybelsus (oral semaglutide): the label's schedule is 3 mg daily for 30 days, then 7 mg, then 14 mg. the label specifies the tablet be taken on an empty stomach with no more than 4 oz of water, and no food or other drugs for the following 30 minutes. oral bioavailability is poor. the 14 mg oral dose corresponds roughly to 0.5 mg subcutaneous in glycemic effect.
reptides editorial · research reference, not medical advice.