Starting GLP-1 Medications: How to Dose, Up-Titrate & Reduce Side Effects of GLP-1

Starting a GLP-1 medication can feel overwhelming, especially with so much misinformation online about dosing, side effects, and “maximum” doses.

In this episode, Dr. Chhaya Makhija explains how GLP-1 dose titration actually works and why more medication is not always better.

From semaglutide medications like Ozempic and Wegovy to tirzepatide options like Mounjaro and Zepbound, she shares how she approaches dosing with her own patients, what signs she monitors, and why individualized care matters so much in metabolic health.

She also discusses body composition, inflammation, side effect management, oral GLP-1 medications, and the importance of ongoing communication with your healthcare provider throughout your journey.

Whether you’re considering starting a GLP-1 medication, currently adjusting your dose, or simply trying to better understand how these medications work, this episode offers a realistic approach to metabolic health and weight management.

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Transcript

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So today I'm going to break down the starting doses for the most commonly used GLP1 medications, what they are, what they actually mean clinically, how do I approach the titration, meaning changing of the dose, either increasing it or reducing it with my own patients. I'm going to cover semaglutide, that is Wigovian or Zempic, as well as Tersopatide, that is Monjaro and Zeppound. These are all FDA-approved versions. And at the end, we'll touch base on the oral pills and the information on the starting doses for those. Welcome to Hormones and Hope, a podcast where we bridge science and wellness to help transform your health. I'm your host, Dr. Chaya Makija, or you can call me Dr. Chaya, a triple board certified endocrinologist and lifestyle medicine physician and founder of Unified Endocrine and Diabetes Care. Each week we dive into the powerful intersection of clinical medicine and real-life lifestyle strategies to help you feel stronger, live longer, and show up as your most vibrant self inside and out. So let's get empowered. Hi everyone, this is Dr. Mikaja, your triple boat certified endocrinologist, lifestyle medicine specialist, and your metabolic hormone expert. So how many of you have wondered, if I still have a low dose of GLP1, does that mean it's not gonna work? Or maybe you've heard someone say that they're on a maximum dose and still don't feel anything or haven't lost the weight that they wanted to. Or someone else you tried the lowest dose for a week or two, and then they ended up jumping very rapidly to higher doses, and they mentioned that they just felt awful. So today I'm gonna break down the starting doses for the most commonly used GLP1 medications, what they are, what they actually mean clinically, how do I approach the titration, meaning changing of the dose, either increasing it or reducing it with my own patients. I'm gonna cover semaglutide, that is Vigovian or Zempic, as well as Terzepatite, that is Monjaro and Zeppmount. These are all FDA-approved versions. And at the end, we'll touch base on the oral pills and the information on the starting doses for those. So before we go further, if you haven't watched my videos on GLP1, which we just released in the last few months in relevance to what these are, what your health goals should be, what is body composition, why we focus on muscle mass, then go ahead and watch what's the difference between Rigovi, Ozempic, Manjaro, and Zeppound. Uh, the links will be in the description. Alright, so now let's move on to the topic today about starting doses. Semaglutide, Rigovi, and Ozempic. You're gonna start with that. Now, the starting dose for semaglutide, which is the FD-approved version, again, I'm not talking about compounded versions in this video or in any of my videos. So the starting dose for semaglutide is 0.25 milligrams injected once weekly. I want to be transparent with you that clinically, 0.25 milligrams is considered a subtherapeutic dose, right? It's a starting dose. It is designed to help initiate the new medication so that you understand what the response of the medication is and not necessarily immediately drive to uh significant metabolic changes or weight loss. And that's why it's called subtherapeutic. Okay. In clinical trials, the standard titration is to start with these low doses and then step up every four weeks to a specific maximum tolerated dose and it's individualized. Again, this is the clinical trials. But clinically, that means when I am with my patients or what happens when you're seeing a specialist, like an obesity medicine uh certified specialist or an endocrinologist, that's where I'm going to dive into more nuances. When a patient starts, typically 0.25 milligrams, what I do is I give them a checklist that we've decided about which day to start or which evening to start. I've asked them to note down the date that was the first dose and then send me a message in regards to how they were feeling 24 hours later and then a couple of days later, and we continue with that journey of weekly touch base. Now, what are you expecting? Was there any nausea? Was there a sense of bloating? Was there some funny sensation in the belly? Bloating, diarrhea, fullness, you know, I didn't feel like eating, or maybe I just felt a little tired, or there was this minor headache, how was the appetite? I don't expect to have someone express all of these effects or side effects per se, but these are good ones to discuss with your patient, and then they can be much more aware as to what should I be noticing or discussing with my clinician. If my patient starts semaglutide that is ozempic for glycemic control, for which it is approved, I also suggest a use of continuous glucose monitors because that's a great way to also see the changes in the glucose levels, which can be seen early on as compared to the other weight loss or metabolic changes. Now, here is something that's very surprising for people as well as for my patients. I regularly see meaningful changes in your metabolic health, in my patients specifically, even at the subtherapeutic starting dose. I have so many women who start at 0.25 milligram dose who either are in that category of BMI overweight or obesity with other specific obesity-related complications or risk factors, and they are on the same dose for eight weeks and average between 8 to 15 pounds of weight loss just with this low dose, the subtherapeutic dose. But remember, lifestyle interventions are overlapping it. The foundations are being discussed every week and they're getting better and better, right? So that's why it's very important that it doesn't mean that you start with the low dose or the starting dose and you cannot be on it for longer than four weeks. Of course, you can because it's your body. That's why it's very important to have a shared decision making. I also will recommend that you have this discussion periodically with your prescribing clinician. You should never be receiving a GLP1 prescription with start with 0.25 milligram and specifically with semaglutide, start with 0.25, in a month increase to 0.5, next month increase to 0.75 or 1 milligram, then keep on increasing to the maximum dose. No, this is not how medicine works. It has to be discussed between you and your physician and where are you at, how are you tolerating it. And most of the times my patients actually tell me, Dr. Makizo, I'm ready for the step up because they have overlapped uh both of these the lifestyle interventions, and also have understood how my body feels with the the starting dose, and now I'm ready to step up. Now, once there is this titration adjustments from 0.25 to 0.5, this is where I ask my patients to give it real time. You know, in some cases, 8 to 12 weeks is a good place, that is 2 to 3 months, to assess while I'm working simultaneously with them on nutrition, sleep, lifestyle, activity, addressing any underlying contributors to the metabolic health, like hormone replacement or fired hormone adjustment, or they might be anemic or any vitamin deficiency that were present beforehand, have they all been addressed? And that's when I will see results that they will eventually in those two, three, four months, have a significant weight loss with stabilization, preservation of lean body mass, or slight increase. And when I say lean body mass, that includes the muscle mass and the drop in body fat percentage. Now, how do I know this? That's because I keep monitoring their body composition periodically, and if they don't have a body composition access available, I have them buy a scale, which is a home scale, which doesn't just give you the weight in pounds or kilograms, but actually the body fat percentage and just an idea of what the lean body mass or the muscle mass is, right? So this is going to be very crucial for you to know that a low dose doesn't mean that it's not going to be effective. It's so personalized that as we are learning more and more, and as people have been using these medications for specific indications, and as an endocrinologist, I've been using these medications since 2007. We do see a transformation, and every patient has their own dose, right? So clinical trials are there for every approval for us to know what exactly happened. And then as clinicians, it is individualized based on their biology, based on their metabolic risk factors, based on their response. So the conclusion is that you don't necessarily have to rush to the next dose every month. Now, when is another good time to have a conversation with your clinician? Is if there's a plateau, not just for the weight, but also you've been really amplifying your lifestyle interventions and you're checking all the other boxes, then it's a good time to have a discussion. The other is the glycemic control, that means a blood sugar control. If the clinical picture warrants it, that is you're having this conversation with your clinician about how am I responding, what am I working on, how do I feel, how are my bowel movements, shouldn't be constipated for days and still think that titration of the dose is going to be wise or prudent. You want to fix that, you want to mitigate the side effects, you want to mitigate those secondary effects of hair loss, fatigue by making sure you're hydrated well, making sure you're getting your nutrients, your micronutrients, and so on. And again, I put a deep dive in my other videos. So tune in to those videos so that you get a plethora of the understanding and knowledge in relevance to titration of GRP1 medications. Now, today I'm recording this episode May 2026, and very recently, just a few weeks ago, we had uh the FD approval of Vigovi maximum dose of 7 mg. But this video is basically made for Vigovi 2.4 mg weekly or Zempic 2 mg once weekly in regards to the titration. And I'll make another video on the other doses of Vigovi in a separate video. So now I hope you get the understanding that it doesn't matter if you're on a low dose, a starting dose, and if you're getting the results, the outcomes, that may be a good dose for you, and you don't have to step up on the next dose every month, but get that body awareness, get your metabolic pattern in terms of understanding own your lifestyle interventions. Make sure you're hydrating yourself, you're adding on the nutrients, you're figuring out your routine on how am I gonna feed myself, how am I gonna engage in physical activity, and then step up. Alright, my friends. Now we're gonna shift to trisipatide. Trisipatide is manjaro and zep bound. These are dual GIP, GLP1 receptor agonist available as Zepbound for weight management or for obstructive sleep apnea and manjaro for type 2 diabetes. Starting dose is 2.5 milligrams, very different. Okay. First, it's dual hormones, right? So the 2.5 milligram of trzepatite is actually a therapeutic dose. A therapeutic dose, it's not a low dose. And so many of my patients do phenomenally well metabolically and clinically in terms of how they feel, the inflammation, the lightness, the change in the body weight, the energy, and of course, we are mitigating the side effects, which are either diarrhea, nausea, constipation in regards to this specific medication. Now, if you wanted more details, I do have a GLP 1 handout, six-page handout, which dives it into even further. And the link is again in the show notes. It's a free download. Again, all evidence-based discussion. So you're more than welcome to read through it and get an a better understanding as well. Okay, so now since we know our goals that uh we are on the 2.5 milligram, and what are we monitoring? Monitoring is similar to what I discussed with 0.25 milligram dose of Agovir or Zimpic. So same principles apply here. You're combining the medication with lifestyle intervention, optimizing nutrition, building lean body mass, and addressing all the other contributors to metabolic health simultaneously. And this is where the results come from. If at around eight weeks or average two months, the patient is tolerating 2.5 milligrams, but I'm not seeing that metabolic progress where we are working towards and we decide on our health goals even before we start the GRP1, then we discuss about stepping up to 5 milligrams once weekly. Again, it's a shared decision making. It's not that there is a prescription just sent and patient is not aware. It's a simultaneous discussion with the patient so that they feel comfortable and they feel like they are ready for the next step up. Now, what I want you to understand that there is a response in the inflammation and joint pain in the energy, it's the body composition, clothes really fitting well, even though you may not see the change in the weight, all these can happen at your starting dose, which is a positive response. In my patients with terzepatite, that is Zeppelin, I've seen patients achieve between 50 to almost 40 pounds of the fat loss with improvement in their lean body mass with the work that they are putting in, with that 2.5 milligram to 5 milligram dose by itself. So I barely have to step up to very, very high doses for most of my patients. And there's a reason for it. So individual biology, individual response is going to be very important for the clinician to understand and to educate their patients so that there is a happy and healthy dose for you. Now we're going to talk about lyraglutide, which is a daily GLP1 receptor agonist. Again, we've had it for quite a number of years. It's also available as generic, and the starting dose is around 0.6 milligram. It's injected daily. It's a very low dose, and the titration is generally slower because it's a daily injectable. But you can step it up every one to two months based on the tolerance that we talked about in the earlier part of our video. In regards to oral agents, now if you haven't watched my video on Wingovi pill versus fundio, just the basic differences, go watch that episode because it's really going to help you to understand the nuances of pills before you decide that this is going to be the choice for you. Now, the oral agents, the titration is different, the conversation is going to be somewhat different. There is a higher tendency of having gastrointestinal side effects or a higher tendency in patients using the oral pills, that is Vigovi F and dial. And the critical trial response in terms of weight loss is less as compared to what we've seen in the injectable medications. But again, you don't have head-to-head trials comparing oral and injectable at the same time to tell you the exact head-to-head comparison or the differences. But my advice to patients, clinicians is go slow. And if you were a patient using or thinking about OL GLP1, you know, discuss it with your clinician and how you're feeling when you start the low dose. What are you experiencing? Any side effects that are not tolerable, don't keep it to yourself, but have this mutual discussion. You may need switching of the formulation, you may need switching of an injectable at a certain point if you feel that it's intolerable rather than feeling that all the doors are closed. And the best way is to avoid rapid obtitration with any of the GLP1, be it orals, be it injectables, because that's where patients will feel the side effects or may just feel like their body is not accepting this medication because of rapid uptitration. So it's a nuanced conversation, but if you have direct access to your prescribing clinician, I would highly encourage to have these conversations with you. Now, regular check-ins are very important. You can't see a physician every four or five, six months while you're on this journey of titration where you've just started and your GLP1 doses are being adjusted. It's very important to have a one-on-one clinician discussion. Your metabolic markers should be looked at, and of course, the symptoms that I talked about. My last tip for you is seek a both certified obesity medicine specialist, endocrinologist, your internist with real experience in metabolic health, who knows all the nuances, who've been keeping updated with all the GLP1FD approved versions and knows the differences. And also have a chat, have a discussion with them about hecturation and what they are following. Thanks for hanging out with me on hormones and hope. If you've loved this episode, do me a favor, hit subscribe, share it with someone you care about, and drop a review if you're feeling generous. Want more tools to support your hormones and health? Head over to unified endocrine care.com. We've got free guides, resources, and more waiting for you. Until next time, stay curious, stay kind to your body, and keep your hormones happy.