What is the next step for a patient with ongoing pain despite being on 15 mg daily of Mobic (meloxicam)?

Management of Pain in a Patient on Maximum Dose of Meloxicam

For a patient already on 15 mg daily of meloxicam (Mobic) with persistent pain, the next step should be switching to an opioid analgesic or adding adjuvant therapy such as gabapentin or pregabalin, depending on the pain type.

Assessment of Current Situation

• 15 mg daily of meloxicam represents the maximum recommended dose for this NSAID
• Continuing to increase the meloxicam dose beyond 15 mg is not recommended as:
  • No additional analgesic benefit is likely
  • Risk of adverse effects increases significantly
  • Nephrotoxicity risk increases, particularly in patients over 60 years, those with compromised fluid status, or those taking other nephrotoxic medications 1

Next Steps Based on Pain Type

For Nociceptive Pain:

1. Add or switch to an opioid analgesic:

   • Begin with a short-acting opioid for titration 2
   • Options include:
     • Morphine 10-15 mg every 4 hours as needed
     • Oxycodone 5-10 mg every 4-6 hours as needed
     • Hydromorphone for patients with intolerance to morphine 2

2. Titration approach:

   • Initial titration can be done with immediate-release formulation
   • Rescue doses should be calculated as 10% of the daily opioid dose 2
   • Once stable dosing is established, consider switching to long-acting formulation for around-the-clock pain control 2

For Neuropathic Pain:

1. Add adjuvant medications:

   • Gabapentin: Start 100-300 mg at bedtime or 100-300 mg three times daily; increase by 100-300 mg every 1-7 days as tolerated; maximum dose 3600 mg/day in 3 divided doses 2
   • Pregabalin: Start 50 mg three times daily or 75 mg twice daily; increase to 300 mg/day after 3-7 days, then by 150 mg/day every 3-7 days as tolerated; maximum dose 600 mg/day 2
   • Duloxetine: Start 30 mg once daily; increase to 60 mg once daily after 1 week; maximum dose 60 mg twice daily 2

2. Consider topical agents:

   • 5% lidocaine patch for localized neuropathic pain with allodynia 2
   • Diclofenac gel or patch as an alternative NSAID approach 2

Non-Pharmacologic Interventions

• Physical therapy for improved function and pain management
• Cognitive behavioral techniques for pain coping skills 2
• Consider referral for interventional pain procedures if appropriate

Monitoring and Follow-up

• Assess response to new therapy within 1-2 weeks
• Monitor for adverse effects of new medications
• If using opioids, implement appropriate monitoring for efficacy and side effects
• For patients on gabapentinoids, monitor for dizziness and sedation, especially in elderly patients 2

Important Considerations

• Avoid continuing to increase the meloxicam dose beyond 15 mg daily
• Avoid adding another NSAID due to increased risk of GI, renal, and cardiovascular toxicity
• Avoid using meperidine for chronic pain management 2
• For elderly patients or those with renal impairment, use lower starting doses of adjuvant medications and titrate more slowly 2

By implementing these evidence-based strategies, pain control can be optimized while minimizing the risk of adverse effects from excessive NSAID use.