The standard semaglutide titration ladder
The FDA-approved Wegovy label specifies a 5-step weekly subcutaneous titration over 16 weeks before reaching the 2.4 mg maintenance dose. Compounded prescribing protocols typically follow this same schedule, though some compounded providers offer flexibility (slower titration for patients with intolerance, faster titration in select cases under clinician judgment).
| Step | Weekly dose | Duration | Volume (example 2.5 mg/mL concentration) |
|---|---|---|---|
| 1 | 0.25 mg | Weeks 1-4 | 0.10 mL |
| 2 | 0.50 mg | Weeks 5-8 | 0.20 mL |
| 3 | 1.0 mg | Weeks 9-12 | 0.40 mL |
| 4 | 1.7 mg | Weeks 13-16 | 0.68 mL |
| 5 (maintenance) | 2.4 mg | Week 17 onward | 0.96 mL |
The 2.4 mg maintenance dose is held indefinitely as long as the patient tolerates it, achieves clinical response (≥5% weight reduction by week 16-20), and remains on therapy. STEP-1 trial data showed continued weight loss through week 60-68 at the 2.4 mg dose.
Reconstitution math: how to think about vial concentration
Compounded semaglutide is typically dispensed as a lyophilized powder requiring reconstitution with bacteriostatic water (BAC water), or as a pre-mixed solution. The math depends on the vial size and concentration.
Example: 5 mg vial reconstituted with 2 mL BAC water
- Final concentration: 5 mg ÷ 2 mL = 2.5 mg/mL
- For 0.25 mg dose: 0.25 ÷ 2.5 = 0.10 mL (10 units on a U-100 insulin syringe)
- For 2.4 mg dose: 2.4 ÷ 2.5 = 0.96 mL (96 units)
Example: 5 mg vial reconstituted with 2.5 mL BAC water
- Final concentration: 5 mg ÷ 2.5 mL = 2.0 mg/mL
- For 0.25 mg dose: 0.25 ÷ 2.0 = 0.125 mL (12.5 units)
- For 2.4 mg dose: 2.4 ÷ 2.0 = 1.2 mL (120 units — exceeds standard U-100 syringe; would require split injection or larger syringe)
Always confirm reconstitution instructions with the prescribing pharmacy. Pre-mixed solutions are the safer option for patients without compounding-pharmacy experience.
Injection technique
- Sites: abdomen (2 inches from navel), front of thigh, or back of upper arm
- Frequency: once weekly, same day each week
- Needle: 27-31 gauge, 1/2 inch (12.7 mm) insulin syringe with U-100 markings
- Rotation: rotate injection sites to reduce lipohypertrophy
- Timing: no food restriction; can be given any time of day
- Storage: refrigerate reconstituted vials (2-8°C); some compounded products are stable at room temperature for limited durations — check BUD (beyond-use date) on label
Missed doses
- ≤5 days late: take the missed dose as soon as remembered, then resume normal weekly schedule
- >5 days late: skip the missed dose entirely; take the next scheduled dose on the regular day
- 2+ consecutive weeks missed: consult prescriber — may need to restart at a lower dose to avoid GI re-titration symptoms
Managing side effects by dose
| Dose | Common side effects | Management |
|---|---|---|
| 0.25-0.5 mg | Mild nausea (20-30%), constipation, fatigue | Smaller meals, ginger tea, hydration |
| 1.0 mg | Moderate nausea (peak window), diarrhea or constipation | Hold escalation if needed; consider 8-week step instead of 4 |
| 1.7-2.4 mg | GI symptoms usually plateau or decrease; appetite suppression peak | Protein-first eating; resistance training to preserve lean mass |
When to deviate from the standard ladder
Clinicians may modify the standard ladder for:
- Severe nausea at any step: hold dose for 4 additional weeks before escalating, or downtitrate to previous step
- Slow weight loss response (<5% by week 16): consider continued escalation to 2.4 mg or evaluation of adherence/lifestyle factors
- Maximum tolerated dose < 2.4 mg: some patients maintain weight loss on 1.0 mg or 1.7 mg long-term
- Drug holiday (per prescriber): not recommended; STEP-4 data shows substantial regain after discontinuation
Provider pricing for compounded semaglutide (May 2026)
Compounded semaglutide telehealth pricing varies substantially by provider and dose-escalation policy. Some providers raise prices as the patient titrates to maintenance dose; flat-rate providers keep the same monthly price across the full ladder.
| Provider | Starter dose | Maintenance (2.4 mg) | Pricing model |
|---|---|---|---|
| NexLife | $145/mo (12-mo plan) | $145/mo (same) | Flat-rate, dose-independent |
| Mochi Health | ~$178/mo (membership tier) | ~$257/mo total | Tier-based |
| Henry Meds | ~$279/mo | ~$279/mo | Flat-rate, single price |
| Hims & Hers | ~$199/mo | ~$299/mo | Tiered by dose |