Is meloxicam appropriate for a 68-year-old man with osteoarthritis and uncontrolled pain who has coronary artery stents and is on clopidogrel and aspirin?

Meloxicam is NOT appropriate for this patient and should be avoided

NSAIDs, including meloxicam, are contraindicated in patients with coronary artery stents on dual antiplatelet therapy due to significantly increased cardiovascular risk, including stent thrombosis, myocardial infarction, and cardiovascular death. 1

Why NSAIDs Must Be Avoided in This Patient

Cardiovascular Risk with Stents

• All oral NSAIDs and COX-2 inhibitors carry substantial cardiorenal toxicity that is particularly dangerous in patients with established coronary artery disease 1
• The European Heart Society explicitly states that NSAIDs should be avoided in patients with cardiac stents due to increased cardiovascular risk 2
• NSAIDs interfere with the cardioprotective effects of aspirin and can increase thrombotic complications in stented patients 1

Interaction with Antiplatelet Therapy

• This patient requires mandatory continuation of aspirin 75-162 mg daily plus clopidogrel 75 mg daily for his coronary stents 1, 3
• NSAIDs should not be used concurrently with dual antiplatelet therapy, as this substantially increases bleeding risk without providing cardiovascular benefit 3
• The AHA/ACC guidelines specifically recommend considering other analgesics before substituting with or adding an NSAID in patients on low-dose aspirin 1

Recommended Alternative Pain Management Strategy

First-Line Approach

• Paracetamol (acetaminophen) at regular dosing should be the initial analgesic choice for osteoarthritis pain 1
• Paracetamol can be dosed up to 1000 mg four times daily (4000 mg/day maximum) for adequate pain control 1

Second-Line Options if Paracetamol Insufficient

• Topical NSAIDs (such as diclofenac gel) can be considered for knee or hand osteoarthritis, as they have minimal systemic absorption and lower cardiovascular risk than oral NSAIDs 1
• Topical capsaicin may provide additional benefit for localized joint pain 1

Opioid Therapy as Safe Alternative

• Opioid analgesics are appropriate and safe in this patient population when NSAIDs are contraindicated 1, 2
• Buprenorphine transdermal patch (Butrans) is specifically noted as safe, as it does not interfere with guideline-directed coronary artery disease therapies including aspirin, P2Y12 inhibitors, beta-blockers, and statins 2
• Opioids like buprenorphine do not increase thrombotic risk, unlike NSAIDs 2
• No modification of dual antiplatelet therapy is required when initiating opioid therapy 2

Additional Non-Pharmacological Interventions

• Strengthening exercise and aerobic fitness training should be core components of osteoarthritis management 1
• Weight loss if overweight or obese (BMI reduction toward 18.5-24.9 kg/m²) 1
• Local heat and cold applications 1
• Assistive devices (walking sticks, joint supports) for biomechanical support 1
• Intra-articular corticosteroid injections for moderate to severe pain in specific joints 1

Critical Antiplatelet Therapy Requirements

Mandatory Continuation

• Aspirin 75-162 mg daily must be continued indefinitely unless contraindicated 1, 3
• Clopidogrel 75 mg daily should be continued for at least 12 months after stent placement, and potentially longer depending on stent type and clinical circumstances 1, 3
• Dual antiplatelet therapy should never be interrupted for pain management, as there is no need to modify DAPT when using appropriate analgesics 2

Gastrointestinal Protection

• Proton pump inhibitors should be prescribed routinely to reduce gastrointestinal bleeding risk with dual antiplatelet therapy 3
• Use pantoprazole or esomeprazole preferentially rather than omeprazole, as omeprazole significantly reduces clopidogrel's antiplatelet activity through CYP2C19 inhibition 3

Common Pitfalls to Avoid

• Never prescribe meloxicam or any oral NSAID in patients with coronary stents on antiplatelet therapy 1, 2, 3
• Do not discontinue antiplatelet therapy to accommodate pain management—choose analgesics compatible with DAPT 2
• Avoid the misconception that COX-2 selective NSAIDs are safer in cardiovascular disease—they carry similar or greater cardiovascular risk 1
• Do not use topical NSAIDs on multiple large joints simultaneously, as this increases systemic absorption and cardiovascular risk 1