Meloxicam: a once-daily NSAID for arthritis

The UK product information describes meloxicam as an NSAID of the oxicam family with anti-inflammatory, painkilling and fever-reducing properties. Tablets are indicated for the short-term symptomatic treatment of acute flare-ups of osteoarthrosis and for long-term symptomatic treatment of rheumatoid arthritis or ankylosing spondylitis, in adults and in children aged 16 and over.

It says meloxicam is not suitable for people who need relief from acute pain, and that if there is no improvement after several days the clinical benefit should be reassessed. It is a once-a-day tablet, which is part of its appeal for long-term conditions.

The daily dose is taken all at once, and prescribers aim for the lowest effective dose for the shortest time. For osteoarthritis flare-ups the starting figure given is 7.5mg a day, which may be increased to 15mg if there is no improvement. For rheumatoid arthritis and ankylosing spondylitis the figure is 15mg a day, which may be reduced to 7.5mg depending on response. The information says not to exceed 15mg a day.

People at increased risk of side effects, such as those with a history of gut problems or cardiovascular risk factors, should start at the lower dose, as should older people on long-term treatment for rheumatoid arthritis and ankylosing spondylitis. It is contraindicated in severe kidney failure not on dialysis. The need for treatment is re-evaluated periodically.

The contraindications include the third trimester of pregnancy; being under 16; hypersensitivity to meloxicam or similar substances such as other NSAIDs and aspirin, including asthma, nasal polyps, angioedema or hives after taking them; a history of gut bleeding or perforation related to previous NSAID use; active or recurrent stomach ulcer or bleeding (two or more episodes); severely impaired liver function; severe kidney failure without dialysis; other gut bleeding, cerebrovascular bleeding or bleeding disorders; and severe heart failure.

Caution is advised in people with a history of oesophagitis, gastritis or ulcers, and in those with ulcerative colitis or Crohn disease, which can be worsened by NSAIDs. People with a history of high blood pressure or mild to moderate heart failure need appropriate monitoring.

The most commonly observed events are gastrointestinal: indigestion, nausea, abdominal pain and, less often, ulcers, perforation or bleeding, which can be fatal, especially in older people. Oedema, high blood pressure and heart failure have been reported with NSAIDs, and long-term high-dose NSAID use may be associated with a small increased risk of arterial thrombotic events such as heart attack or stroke.

Severe skin reactions such as Stevens-Johnson syndrome and toxic epidermal necrolysis have been reported. Seek urgent help for black stools or vomiting blood, chest pain, weakness on one side, breathing difficulty, facial swelling, or a spreading blistering rash. Anaemia and blood count abnormalities are also listed, which is one reason monitoring matters in long-term use.

Inhibiting prostaglandin synthesis may adversely affect pregnancy or fetal development, and epidemiological data suggest an increased risk of miscarriage and heart malformations after use in early pregnancy. In the first and second trimester it should not be given unless clearly necessary, and if used by a woman trying to conceive or in those trimesters the dose should be kept as low and the duration as short as possible.

In the third trimester all prostaglandin synthesis inhibitors can expose the baby to heart and lung toxicity (premature closure of the ductus arteriosus) and kidney dysfunction, and the mother to prolonged bleeding and delayed or prolonged labour, so meloxicam is contraindicated then. As with any drug that inhibits cyclo-oxygenase, it may impair female fertility and is not recommended for women trying to conceive.

The product information warns that combining with other NSAIDs (including COX-2 inhibitors) or anti-inflammatory doses of aspirin raises the risk of gut effects. Corticosteroids add to the risk of ulceration and bleeding. NSAIDs can enhance anticoagulants such as warfarin, raising bleeding risk, so careful INR monitoring is needed if the combination cannot be avoided; the risk with heparin, thrombolytics and antiplatelet agents is also described.

Several medicines raise potassium or affect the kidneys: potassium salts, potassium-sparing diuretics, ACE inhibitors, angiotensin II blockers and others, so the risk of high potassium rises when combined with meloxicam. Tell your prescriber about every medicine, including over-the-counter anti-inflammatories.