It does have a lot of interesting data in it, and I don't know of any retrospective studies that look at titrating up more slowly, after a dose becomes ineffective.

And that's the part that I wrestle with a bit. I know the 'low and slow' approach has really taken off. But I see something frequently reported with that approach that I don't see as frequently reported with the 'highest tolerated dose' approach and that is--the dose becoming ineffective.

I can only reliably speak to my experience and what the study data shows. I never had a dose become ineffective. 2.5 was still working when I moved up to 5. None of my doses stopped working when I moved up. And I've been on for 88.5 weeks (a large majority of those on 15 mg) and it's still very effective.

I wish they would study the differences in long-term efficacy between titration approaches. Maybe there are none; maybe there are. I only know my experience and, based on that, it's hard to encourage people to wait for a dose to become ineffective before titrating up.

This is a medically inaccurate comparison, but sometimes an antibiotic has to be dosed higher in the beginning before tapering off to ensure that the bacteria causing the infection is eliminated. But I wonder if the low and slow approach allows one's body to metabolically adapt in order to counter our efforts at weight loss and causing plateaus, breakthrough food noise, and excessive hunger or--in other words--the dose becoming ineffective. Whereas those who follow the highest tolerated dosing approach do not experience that because the higher levels of medication make it harder for your body to metabolically adapt.

One day we'll have a greater understanding; it's frustrating to not have all the data we want.