What I have: 1.7 mg · dulaglutide.
This is a planning question. I know what my options are; I do not know how to weigh them.
What I want is the minimum viable version, which I suspect is smaller than what I would design.
How do I make this decision on evidence rather than on feel?
1.7 mg a week is 0.243 mg a day averaged out and 88 mg over a year — but "defensible" is not a property of the number, it is a property of where the number came from. A maintenance dose is defensible when a trial randomised people to it and reported what happened, and indefensible when it was arrived at by interpolation between two doses that were studied. So the question to ask of 1.7 mg is which arm it corresponds to: if a programme ran 1.7 mg as a maintenance level, there is an efficacy figure, a tolerability figure and a discontinuation rate attached to it. If it sits between two studied levels, everything said about it is extrapolation, and the burden of that is on whoever proposed it. The other half of the arithmetic is supply: at 1.7 mg a week a 10 mg vial is 5.88 weeks and you will need about 9 of them a year, which is worth knowing before the dose is settled rather than after. Maintenance doses are set by a prescriber against an individual; nothing here is medical advice.
The honest answer is that the maintenance dose is individual and that the search for it is slow because the feedback is slow.
A downward search proceeds one step at a time with at least eight weeks at each level, because a weekly agent takes four to five weeks to reach the new steady state and then needs time for the trend to be readable.
| Week | Fraction of steady state | Trough as × dose |
|---|---|---|
| 1 | 50 % | 0.50 |
| 2 | 75 % | 0.75 |
| 3 | 88 % | 0.88 |
| 4 | 94 % | 0.94 |
| 5 | 97 % | 0.97 |
| 6 | 98 % | 0.98 |
This is why a four-week step interval is approximately, but not exactly, steady state.
The maintenance dose is not necessarily the same a year later, since the counter-regulatory response attenuates slowly if at all.
The counter-regulatory hormonal response to weight loss persists for at least a year after the loss, which is the physiological reason maintenance needs something rather than nothing.
Search downward, one step, eight weeks each, on a rolling average.
Aggregated, published test results and vendor ratings built from submitted batches. Methodology stated, dataset browsable, no listing fees.
Browse resultsStart with what is being maintained — weight, glycaemia or both — because they have different dose-response curves.
Maintenance and loss are different endpoints. Loss requires a sustained energy deficit; maintenance requires only that the counter-regulatory drive is offset, and that may need less exposure.
It helps to be literal here: glycaemic maintenance has a faster and cleaner signal than weight maintenance, particularly with continuous monitoring, which makes the downward search more tractable when glycaemia is the endpoint.
Dose-response for weight in the trial programmes was real but flattening at the upper end, which is consistent with a lower maintenance requirement.
The caveat is that dose reduction is a clinical decision and this is a description of a search strategy rather than a recommendation.
The withdrawal trials answer stopping, not reducing. Different questions.
The relevant observation is that maintenance frequently requires less exposure than the loss phase did, and the trials suggest it rather than establish it.
If the result deteriorates on a lower dose, returning to the previous one is straightforward and does not require re-titration from the bottom provided the gap has been short.
More usefully, weight is a noisy signal. A rolling four-week average is the instrument; single weigh-ins after a dose reduction will show nothing interpretable.
STEP-4 and SURMOUNT-4 evaluated withdrawal rather than dose reduction, which is the limit of the direct evidence on this question.
A noisy weight signal makes premature conclusions easy, in both directions.
Glycaemic maintenance gives a faster signal than weight maintenance.
edited 23 Jul 2025 by t_oyelaran — added the placebo-arm figures
The relevant detail is that this is a question the trial programmes answered only partially, and it is worth saying which parts are evidenced.
The withdrawal trials — STEP-4 and SURMOUNT-4 — established what happens when treatment stops entirely. They did not evaluate dose reduction, so the evidence for a lower maintenance dose is inference rather than data.
Gastrointestinal adverse event rates in the trials are dose-related, which supports the tolerability argument for the lowest effective dose.
The lowest dose that holds the result is the answer, and it is individual.
edited 23 Jun 2025 by Dr_Ilse_Vandenberg — fixed an arithmetic slip in the third paragraph
The short version: reach a working dose, hold it, and then consider whether less would hold it just as well.
Gastrointestinal tolerability generally improves on a reduced dose, which is a genuine quality-of-life argument for the search rather than only a cost one.
The STEP programme escalated semaglutide over sixteen weeks in four-week steps to 2.4 mg weekly, and the trial-product estimand versus treatment-policy estimand distinction accounts for most of the difference between the figures quoted from those papers.
Going back up after a short gap does not require re-titrating from the bottom.
Ask PeptideStack is a static archive. Posting is closed, but the norms are worth stating: answer the question that was asked, show your working, cite the trial or the certificate, and say plainly where the evidence runs out.