Is it safe for a patient taking meloxicam (nonsteroidal anti-inflammatory drug, NSAID) to also take indomethacin (nonsteroidal anti-inflammatory drug, NSAID)?

From the Guidelines

I would strongly advise against switching from meloxicam to indomethacin without a compelling medical reason, as indomethacin has a higher risk of gastrointestinal side effects and other adverse events compared to meloxicam. Both medications are nonsteroidal anti-inflammatory drugs (NSAIDs) that work by inhibiting cyclooxygenase enzymes to reduce inflammation and pain. However, indomethacin tends to have a higher risk of side effects, particularly gastrointestinal issues, headaches, and dizziness compared to meloxicam 1. The risk of gastrointestinal complications, such as ulcers and bleeding, is a significant concern with NSAID use, and indomethacin is no exception 1. In fact, studies have shown that the annual incidence of hospital admission for upper gastrointestinal events (UGIE) is higher with indomethacin compared to other NSAIDs, including meloxicam 1.

Some key points to consider when evaluating the switch from meloxicam to indomethacin include:

• The patient's medical history, including any history of gastrointestinal issues or bleeding disorders
• The patient's current medications, including any anticoagulants or other NSAIDs that may increase the risk of adverse events
• The specific condition being treated, and whether indomethacin has shown particular benefit for that condition
• The potential risks and benefits of switching medications, including the risk of gastrointestinal complications and other adverse events

It's essential to weigh these factors carefully and discuss them with the patient's healthcare provider before making any changes to their medication regimen. As noted in the consensus development conference on the use of nonsteroidal anti-inflammatory agents, clinicians should prescribe the lowest effective dose for the shortest duration and consider the use of gastroprotective therapies to modify GI risk 1.

In terms of specific guidance, the American College of Cardiology Foundation Task Force on Clinical Expert Consensus Documents recommends that a gastroprotective therapy should be prescribed for at-risk patients taking NSAIDs, including those with a history of gastrointestinal issues or bleeding disorders 1. Additionally, the use of proton pump inhibitors (PPIs) or histamine H2 blockers may be considered to reduce the risk of gastrointestinal complications 1.

Ultimately, the decision to switch from meloxicam to indomethacin should be made on a case-by-case basis, taking into account the individual patient's needs and medical history. The patient's healthcare provider should carefully evaluate the potential risks and benefits of switching medications and discuss them with the patient before making any changes to their treatment plan.

From the FDA Drug Label

The concomitant use of indomethacin with other NSAIDs is not recommended due to the increased possibility of gastrointestinal toxicity, with little or no increase in efficacy. The patient is taking meloxicam, which is an NSAID.

• The use of indomethacin with meloxicam is not recommended due to the increased possibility of gastrointestinal toxicity.
• There is little or no increase in efficacy when using indomethacin with other NSAIDs like meloxicam 2.

From the Research

Patient Requesting Indomethacin While Taking Meloxicam

• The patient is currently taking meloxicam and is requesting indomethacin, which are both non-steroidal anti-inflammatory drugs (NSAIDs) 3, 4, 5, 6, 7.
• Studies have shown that meloxicam and indomethacin have different effects on gastrointestinal permeability and cartilage proteoglycan synthesis 3, 7.
• Meloxicam has been found to preferentially inhibit cyclooxygenase 2 (COX-2) and has a lower risk of gastrointestinal side effects compared to indomethacin 3, 5.
• Indomethacin, on the other hand, has been shown to cause significant alteration of small intestinal permeability and inhibit cartilage proteoglycan synthesis at high concentrations 3, 7.

Comparison of Meloxicam and Indomethacin

• A study comparing the effects of meloxicam and indomethacin on cartilage proteoglycan synthesis found that meloxicam did not inhibit synthesis, while indomethacin did at high concentrations 7.
• Another study found that meloxicam had a lower risk of gastrointestinal side effects compared to indomethacin, but both drugs increased intestinal permeability 3.
• The use of NSAIDs, including meloxicam and indomethacin, has been associated with an increased risk of adverse cardiovascular events, and the risk is heterogenous across different NSAIDs 6.

Considerations for Switching to Indomethacin

• Before switching the patient to indomethacin, it is essential to consider the potential risks and benefits, including the increased risk of gastrointestinal side effects and cardiovascular events 4, 5, 6.
• The patient's individual risk factors, such as age, presence of Helicobacter pylori, and previous history of bleeding, should be taken into account when making a decision 4, 5.
• The use of the lowest effective dose for the shortest possible duration is recommended to minimize the risks associated with NSAID use 5, 6.