What is the recommended adult dosing of meloxicam, its contraindications, common and serious adverse effects, monitoring requirements, and alternative therapies?

Meloxicam: Dosing, Contraindications, Adverse Effects, and Monitoring

Adult Dosing

Start meloxicam at 7.5 mg once daily, with the option to increase to a maximum of 15 mg once daily if needed for adequate symptom control. 1, 2

• The standard starting dose is 7.5 mg once daily for arthritis (osteoarthritis, rheumatoid arthritis, ankylosing spondylitis) 1, 2
• Maximum dose is 15 mg once daily if lower dose provides insufficient relief 2
• Meloxicam has a half-life of approximately 20 hours, allowing once-daily dosing 2, 3
• Critical time limitation: Do not use continuously for more than 2-4 weeks without reassessment, as prolonged NSAID use significantly increases gastrointestinal, cardiovascular, and renal complications 2
• For acute pain conditions, NSAID monotherapy should generally not exceed 1 month 2
• Continuing NSAID monotherapy beyond 2 months is inappropriate for patients with active arthritis 2

Special Population Dosing

• Elderly patients (>65 years): Maximum dose 7.5 mg daily with lower initial doses and slower titration 2
• Renal impairment: Avoid in GFR <30 mL/min/1.73 m²; prolonged therapy not recommended in GFR <60 mL/min/1.73 m² 2

Absolute Contraindications

Meloxicam is absolutely contraindicated in patients with active peptic ulcer disease, chronic kidney disease (GFR <30), and heart failure. 4

• Current active peptic ulcer disease 4
• Chronic kidney disease with GFR <30 mL/min/1.73 m² 2
• Heart failure 4
• History of hypersensitivity to meloxicam or other NSAIDs 4

Relative Contraindications and High-Risk Situations

Use meloxicam with extreme caution (or avoid) in patients with hypertension, history of peptic ulcer disease, H. pylori infection, concomitant corticosteroid or SSRI use, and cardiovascular disease. 4

• Hypertension or poorly controlled blood pressure 4
• History of peptic ulcer disease or H. pylori infection 4
• Concomitant use of corticosteroids or SSRIs (increases GI bleeding risk) 4
• Established cardiovascular disease (NSAIDs increase cardiovascular event risk proportional to COX-2 selectivity) 4
• Age >75 years (GI bleeding risk increases from 1 in 2,100 in adults <45 years to 1 in 110 in adults >75 years) 2
• Concomitant anticoagulant use (increases GI bleeding risk 5-6 times) 2

Common Adverse Effects

The most frequently occurring adverse events are gastrointestinal in nature, affecting approximately 28% of patients, though meloxicam demonstrates significantly fewer GI side effects than traditional NSAIDs. 5, 6

• Gastrointestinal effects (28%): dyspepsia, abdominal pain, nausea 5, 6
• Musculoskeletal system disorders (21%) 5
• Skin disorders (18%) 5
• Respiratory disorders (15%) 5
• Hypertension or worsening blood pressure control (NSAIDs can increase mean BP by ~5 mm Hg) 4, 2

Serious Adverse Effects

Serious gastrointestinal complications (perforation, ulceration, bleeding) occur in 0.1-0.2% of meloxicam patients, significantly lower than traditional NSAIDs like piroxicam (1.2%) or naproxen (2.1%). 7, 6

• Upper GI perforation, ulceration, and bleeding (0.1-0.2% with meloxicam 7.5-15 mg vs 1.2% piroxicam, 2.1% naproxen) 7, 6
• Cardiovascular events: increased risk of death and MI in patients with established CVD (dose-related increases in risk) 4
• Acute kidney injury and worsening renal function 4, 2
• Severe liver injury (rare but can be fatal, most cases occur within 6 months) 4
• Pancytopenia, agranulocytosis, thrombocytopenia (rare) 4

Monitoring Requirements

Monitor renal function if treatment extends beyond 2 weeks, particularly in elderly patients or those with existing renal impairment; blood pressure monitoring is warranted as NSAIDs can increase BP. 2

Baseline Assessment

• Evaluate gastrointestinal risk factors: history of ulcer, previous GI bleeding, use of anticoagulants 2
• Assess cardiovascular risk factors and blood pressure 4
• Check renal function (serum creatinine, GFR) 2
• Pregnancy test if indicated 4

Ongoing Monitoring

• Renal function monitoring if treatment extends beyond 2 weeks, especially in elderly or renally impaired patients 2
• Blood pressure monitoring (NSAIDs can increase BP by ~5 mm Hg) 2
• Regular assessment for gastrointestinal toxicity, edema, and signs of bleeding 4
• Reassess treatment efficacy and need for continuation at 2-4 weeks, then at 12 weeks 2
• Do not ignore cardiovascular risk factors (long-term use increases risk of cardiac ischemic events by 3.5 per 1,000 persons) 2

Temporary Suspension Required

Temporarily suspend meloxicam during intercurrent illness, planned IV radiocontrast administration, bowel preparation, or prior to major surgery. 2

Gastroprotection Strategy

Add a proton pump inhibitor (PPI) for gastrointestinal protection in all high-risk patients, including those >65 years, history of peptic ulcer disease, or concomitant anticoagulant use. 4, 1, 2

• All patients >65 years should receive PPI co-prescription 2, 8
• Patients with history of peptic ulcer disease require PPI 4, 2
• Patients on concomitant anticoagulants, corticosteroids, or SSRIs need PPI 4, 2
• PPI co-prescription reduces NSAID-associated symptomatic ulcers by 50-90% 8
• Consider PPI for any patient requiring treatment beyond 2 weeks 1, 2

Critical Drug Interactions and Pitfalls

Never combine meloxicam with other NSAIDs or aspirin for cardioprophylaxis (if using ibuprofen), as this increases toxicity without improving efficacy. 4

• Do not use more than one NSAID concurrently 4
• Patients taking aspirin for cardioprophylaxis should not use ibuprofen (but meloxicam is acceptable) 4
• Avoid concomitant nephrotoxic drugs and renally excreted chemotherapy 2
• NSAIDs can interfere with antihypertensive medications 4
• Do not continue monotherapy indefinitely without reassessing need for alternative or adjunctive therapies 2

Alternative Therapies

When meloxicam is contraindicated or poorly tolerated, consider acetaminophen as first-line therapy, topical NSAIDs, or tramadol as safer alternatives. 4

Non-NSAID Alternatives

• Acetaminophen: Should be considered as initial therapy for musculoskeletal pain (maximum 4 g/24 hours including hidden sources) 4
• Topical NSAIDs: Safer alternative for localized pain without systemic toxicity 4
• Tramadol: Alternative analgesic for patients who cannot tolerate NSAIDs 4

Disease-Modifying Therapy

• For inflammatory arthritis (RA, psoriatic arthritis, ankylosing spondylitis): Meloxicam should be adjunctive to disease-modifying antirheumatic drugs (DMARDs), not monotherapy 1
• Methotrexate is the anchor drug for rheumatoid arthritis, with NSAIDs used primarily for symptom control 1

Non-Pharmacological Approaches

• Structured exercise programs 4
• Weight reduction for osteoarthritis 4
• Physical therapy 4

Pregnancy and Nursing

Meloxicam is pregnancy category C/D (depending on trimester) and should be avoided during pregnancy and breastfeeding. 4

• Contraindicated in third trimester (risk of premature closure of ductus arteriosus) 4
• Should not be used by nursing mothers 4