Titrating to fast? BMI Dependent?

That comes to 21 lb in three months. Subtracting 5-10 lb of water leaves roughly 11-16 lb of actual loss, or 3.7-5.3 lb monthly. Even the higher end is over half a kilo a week, which is decent though on the slower side. Given your starting weight you must have dieted before; was progress similarly gradual then? Individual responses to hunger and side effects vary widely. In one study 12 mg produced 29 % average loss over a year, but 5-10 % of people lost almost nothing while a similar share lost 40 % or more. You are at least not in the non-responder group, and early low-dose results may not predict long-term outcome. How precise is the calorie tracking? Most people underestimate intake unless they weigh and log literally everything for a full week, then run the numbers through an analyzer.

At 21 lb over three months that is 7 lb or 3.2 kg monthly, so I figured some water loss occurred at the beginning. Your numbers sound accurately tracked. The pace is not especially slow, and the deficit looks reasonable when judged by actual scale movement rather than estimates. Converting 3.2 kg monthly at 7700 kcal per kg of fat gives roughly an 810 kcal daily deficit, though this assumes pure fat loss and ignores lean mass. The prior eight-month deficit and 50 lb loss do matter because metabolic adaptation can lower daily expenditure and shrink the effective deficit. In my own case starting near 145 kg on 1600-1800 kcal, early loss was about 6 kg monthly until weight reached around 90 kg after nine months.

I would stay at 6 mg for two more weeks, making four weeks total at that level, then reassess.

At higher BMI you should use an adjusted calculator because standard formulas like Mifflin-St Jeor or Harris-Benedict overestimate BMR once weight passes a certain point; they were built on leaner groups.

Calculator estimates of daily calorie use can be quite inaccurate. In my experience the starting estimate was 3000-3500 and matched reality at first, but after twelve months the same 1600-1800 calories kept weight stable for over a year, proving the lower number was correct. Rate of weight loss gives a more reliable deficit figure than any calculator, and calculators ignore metabolic adaptation. Using the 3.2 kg monthly loss at 7700 kcal per kg of fat yields about an 810 kcal daily deficit, which seems roughly consistent. A true 1500 kcal deficit would produce faster loss, closer to 5-6 kg per month. I also question how well standard calculators work in long-term severe obesity because the metabolic system is altered and prior large weight loss can keep expenditure suppressed for a long time, possibly permanently.