1. Starting at the max dose

The temptation, especially with a patient who has done their own reading and arrives with a target dose in mind, is to write the prescription at the patient's target.

The right move is to start at a conservative initial dose and titrate up over weeks. Two reasons:

• Adverse events are easier to identify when the dose is climbing. Starting at the max muddies attribution.
• Patient response varies. Some patients need less than the textbook target. Starting low lets you find the patient's effective dose, not the population's.

Standard practice: start at 50% of the target dose, increase weekly or biweekly until target is reached or the patient reports plateau in effects.

2. Ignoring the off-cycle

GH-axis peptides in particular show diminishing returns over continuous use. A patient running sermorelin continuously for six months will see their response curve flatten and may report effects fading.

Build the off-cycle into the prescription, not into a future conversation. The patient who plans for 8-on-4-off from the start does not push back on the break. The patient who has been running continuously for four months treats the off-cycle as a regression.

3. Skipping the lifestyle screen

Peptide therapy works downstream of sleep, protein, and movement. A patient sleeping five hours a night with a sedentary day will not get from a GH-axis peptide what a patient with the basics in place will.

Spend two minutes on the lifestyle screen during the consult. If the basics are markedly off, recommend addressing them for 30-60 days before starting the protocol. The patient who fixes sleep first and then starts the peptide has a better experience than the patient who tries to use the peptide as a workaround for sleep deprivation.

4. Combining too many peptides at once

The temptation is to stack: a GH-axis peptide for body composition, a recovery peptide for training, an immune-supportive peptide on top. The patient asks for it. You can write all three.

The cost is attribution. If the stack works, you do not know which peptide did the work. If something goes wrong, you cannot isolate the cause. Both directions limit your ability to refine the protocol for this patient.

Standard practice: start with one peptide. Hold it for at least one full cycle (8 weeks for most protocols). Add a second only after the first cycle is documented.

5. Treating it like a vending machine

Patients sometimes arrive with a specific prescription request. Some of those requests are appropriate. Some are not.

The consult is a clinical evaluation, not an order form. If the request does not fit the patient's situation, the right move is to explain why and recommend an alternative. Patients who push past clinical pushback are not the ones you want as long-term members of your practice.

The clinicians with the best long-term outcomes are the ones who say "not this protocol" more often than they say "let me write that."