MELOXICAM
Clinical safety rating: avoid
Positive evidence of fetus risks but benefits may outweigh risks in some cases
Selective inhibitor of cyclooxygenase-2 (COX-2), reducing prostaglandin synthesis and inflammation.
| Metabolism | Primarily metabolized by CYP2C9 and CYP3A4; less extent by CYP2C8. |
| Excretion | Approximately 50% renal excretion of unchanged drug and metabolites; 50% fecal excretion via bile. Renal elimination accounts for ~5% unchanged meloxicam; the remainder as metabolites (primarily oxidative and glucuronide conjugates). |
| Half-life | Terminal elimination half-life: 15–20 hours. Clinical context: Allows once-daily dosing; steady-state achieved in 3–5 days. |
| Protein binding | >99% bound to albumin (primarily) and alpha1-acid glycoprotein. |
| Volume of Distribution | 0.1–0.2 L/kg (approx 7–10 L in 70 kg adult). Low Vd indicates limited tissue penetration, primarily confined to plasma and interstitial fluid. |
| Bioavailability | Oral: ~89% (high bioavailability). No significant first-pass metabolism. |
| Onset of Action | Oral: Rapid absorption, with clinical effect (analgesic/anti-inflammatory) typically within 30–60 minutes. Peak plasma concentration at 4–5 hours. |
| Duration of Action | Duration: ~24 hours due to long half-life, supporting once-daily dosing. Clinical note: Anti-inflammatory effect persists beyond plasma levels due to COX-2 inhibition kinetics. |
7.5-15 mg orally once daily; maximum 15 mg/day. For osteoarthritis, rheumatoid arthritis: 7.5 mg once daily, may increase to 15 mg/day if needed. For juvenile rheumatoid arthritis, weight-based dosing.
| Dosage form | TABLET |
| Renal impairment | No adjustment for mild-to-moderate renal impairment (CrCl ≥30 mL/min). Not recommended in patients with CrCl <30 mL/min, dialysis, or progressive renal disease. Use with caution in renal impairment; monitor renal function. |
| Liver impairment | No adjustment for mild-to-moderate hepatic impairment (Child-Pugh class A or B). Contraindicated in severe hepatic impairment (Child-Pugh class C). |
| Pediatric use | For juvenile rheumatoid arthritis (JRA) in patients ≥2 years: 0.125 mg/kg once daily, maximum 7.5 mg per dose. For patients weighing <60 kg: 0.125 mg/kg once daily; for ≥60 kg: 7.5 mg once daily. |
| Geriatric use | Initiate at 7.5 mg once daily; increase to 15 mg only if necessary and with close monitoring. Increased risk of GI bleeding, renal impairment, and cardiovascular events in elderly. Lowest effective dose for shortest duration. |
| 1st trimester | Consult provider |
| 2nd trimester | Consult provider |
| 3rd trimester | Consult provider |
Clinical note
ACE inhibitors and ARBs may have diminished antihypertensive effect Increases risk of serious cardiovascular thrombotic events and GI bleeding.
| Breastfeeding | MELOXICAM is excreted into human milk; M/P ratio unknown. American Academy of Pediatrics considers meloxicam compatible with breastfeeding, but caution is advised due to potential adverse effects on infant's cardiovascular and renal systems. Use lowest effective dose for shortest duration. |
| Teratogenic Risk | Pregnancy Category C (first and second trimesters) and Category D (third trimester). First trimester: Risk of spontaneous abortion and congenital malformations (cardiac, gastroschisis) based on epidemiological studies; NSAIDs inhibit prostaglandin synthesis, which may affect implantation. Second trimester: Continued risk of oligohydramnios and fetal renal impairment. Third trimester: Avoid due to risk of premature closure of ductus arteriosus, oligohydramnios, and neonatal pulmonary hypertension; NSAIDs may prolong labor and increase postpartum hemorrhage. |
■ FDA Black Box Warning
Nonsteroidal anti-inflammatory drugs (NSAIDs) cause an increased risk of serious cardiovascular thrombotic events, including myocardial infarction and stroke, which can be fatal. This risk may occur early in treatment and may increase with duration of use. NSAIDs are contraindicated in the setting of coronary artery bypass graft (CABG) surgery.
| Common Effects | rheumatoid arthritis |
| Serious Effects |
History of asthma, urticaria, or allergic-type reactions after taking aspirin or other NSAIDs; coronary artery bypass graft (CABG) surgery; advanced renal disease; pregnancy starting at 30 weeks gestation.
| Precautions | Cardiovascular thrombotic events, gastrointestinal bleeding and ulceration, hypertension, congestive heart failure, renal toxicity, anaphylactic reactions, skin reactions (e.g., Stevens-Johnson syndrome), hematologic toxicity, and fluid retention. |
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| Fetal Monitoring | Monitor fetal growth and amniotic fluid volume via ultrasound if used during pregnancy; assess ductus arteriosus patency in third trimester. In neonates, monitor for signs of renal impairment, respiratory distress, and bleeding tendencies. |
| Fertility Effects | Reversible inhibition of ovulation and luteal phase defects due to prostaglandin synthesis inhibition; may delay or prevent follicle rupture. Use may impair female fertility and is not recommended in women attempting to conceive. |