What is the recommended initial dose of meloxicam for adults with osteoarthritis or rheumatoid arthritis, and how should the dose be adjusted in elderly patients, those with a history of gastrointestinal ulcer disease, or moderate renal or hepatic impairment?

Meloxicam Starting Dose

For adults with osteoarthritis or rheumatoid arthritis, start meloxicam at 7.5 mg once daily, with the option to increase to 15 mg once daily if needed for adequate symptom control after 2 weeks of treatment. 1

Standard Adult Dosing

• Begin with 7.5 mg once daily as the initial dose for both osteoarthritis and rheumatoid arthritis, which provides effective pain relief with optimal gastrointestinal tolerability comparable to placebo. 1, 2
• If symptom control is inadequate after 2 weeks, escalate to 15 mg once daily, which demonstrates superior efficacy for pain and stiffness while maintaining acceptable tolerability. 2, 3
• The 15 mg dose is supported by the American College of Rheumatology as the standard starting dose specifically for osteoarthritis, though the more conservative 7.5 mg approach minimizes gastrointestinal risk. 4

Elderly Patients

• Use the same starting dose of 7.5 mg once daily in elderly patients, as dose adjustment based on age alone is not required according to pharmacokinetic studies. 5
• However, implement closer monitoring for gastrointestinal, cardiovascular, and renal adverse events in older adults due to their inherently higher baseline risk profile. 1
• Elderly patients are at particularly high risk for NSAID-related side effects including gastrointestinal bleeding, platelet dysfunction, and nephrotoxicity, making vigilant surveillance essential. 6

Patients with History of Gastrointestinal Ulcer Disease

• Prescribe a proton pump inhibitor (PPI) concurrently with meloxicam in all patients with a history of gastroduodenal ulcers or gastrointestinal bleeding, selecting the PPI with the lowest acquisition cost. 1
• High-risk patients requiring gastroprotection include those aged >65 years, individuals with prior GI events, and those taking concurrent aspirin, anticoagulants, or corticosteroids. 1
• The standard 7.5 mg starting dose is particularly appropriate in this population, as it demonstrates gastrointestinal tolerability comparable to placebo while maintaining efficacy. 2

Moderate Renal Impairment

• Start at 7.5 mg once daily and use with extreme caution, as neither the cited guidelines nor research provide specific dose reduction recommendations for moderate renal impairment. 5
• Short-term pharmacokinetic studies suggest moderate renal insufficiency does not significantly alter meloxicam pharmacokinetics, but long-term safety data are lacking. 5
• Avoid meloxicam entirely in patients with severe renal impairment or those at high risk for renal complications, as COX-2 inhibitors carry potential for fluid retention and renal toxicity. 6

Moderate Hepatic Impairment

• Use the standard 7.5 mg starting dose, as short-term studies demonstrate that moderate hepatic insufficiency does not significantly alter meloxicam pharmacokinetics. 5
• No specific dose adjustment is recommended in the available evidence for moderate hepatic impairment. 5

Critical Pre-Treatment Assessment

Before initiating meloxicam, mandatory risk stratification must include: 1

• Gastrointestinal risk factors: history of ulcers, bleeding, concurrent anticoagulant therapy, or corticosteroid use
• Cardiovascular risk: history of heart disease, hypertension, or heart failure
• Renal function: baseline creatinine clearance assessment

Treatment Principles

• Use the minimum effective dose for the shortest duration possible to minimize cardiovascular, gastrointestinal, and renal risks. 1, 4
• Meloxicam should serve as adjunctive therapy to disease-modifying treatments in inflammatory arthritis, not as monotherapy for long-term management. 1
• For osteoarthritis, attempt acetaminophen and/or topical NSAIDs before escalating to oral meloxicam. 1
• Never combine meloxicam with other NSAIDs, as this increases toxicity without improving efficacy. 1

Common Pitfalls to Avoid

• Do not prescribe meloxicam without first assessing cardiovascular, renal, and gastrointestinal risk factors. 1
• Do not use high doses (15 mg) for prolonged periods in elderly patients without compelling indication, as they face disproportionate risk of adverse events. 6
• Do not assume COX-2 preferential agents like meloxicam are completely safe for the gastrointestinal tract in high-risk patients—always co-prescribe PPI prophylaxis. 1
• Do not overlook the potential for fluid retention and cardiovascular risk, particularly in older adults with pre-existing cardiac disease. 6