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Meloxicam

Meloxicam is a nonsteroidal anti-inflammatory drug (NSAID) used to relieve pain, tenderness, swelling, and stiffness associated with osteoarthritis, rheumatoid arthritis, and juvenile rheumatoid arthritis in patients aged 2 years and older.^[1] It is available by prescription in various forms, including tablets, oral suspension, and capsules, and is typically administered once daily due to its long plasma half-life of approximately 20 hours.^[2]^[3] Approved by the U.S. Food and Drug Administration in 2000 under the brand name Mobic, meloxicam preferentially inhibits cyclooxygenase-2 (COX-2) over COX-1, thereby reducing the production of prostaglandins that mediate inflammation, pain, and fever, while potentially minimizing gastrointestinal side effects compared to non-selective NSAIDs.^[4] For adults with osteoarthritis or rheumatoid arthritis, the recommended starting dose is 7.5 mg once daily, which may be increased to 15 mg if needed, while pediatric dosing for juvenile rheumatoid arthritis is weight-based at 0.125 mg/kg once daily, not exceeding 7.5 mg.^[4]^[2] Despite its efficacy, meloxicam carries significant risks, including increased chances of serious cardiovascular thrombotic events such as heart attack and stroke, as well as gastrointestinal bleeding, ulceration, and perforation, particularly in long-term use or higher doses.^[1] It is contraindicated in patients with known hypersensitivity to NSAIDs, a history of asthma or urticaria induced by aspirin or other NSAIDs, and for perioperative pain management in coronary artery bypass graft surgery.^[4] Common side effects include abdominal pain, diarrhea, indigestion, and headache, while serious adverse reactions may involve allergic responses, liver or kidney impairment, and severe skin reactions like Stevens-Johnson syndrome.^[2] Patients are advised to use the lowest effective dose for the shortest duration necessary and to avoid use in late pregnancy due to potential fetal harm.^[1]

Medical uses

Indications in humans

Meloxicam is primarily indicated for the relief of pain and inflammation associated with osteoarthritis (OA) and rheumatoid arthritis (RA) in adults. It is also approved for the treatment of juvenile idiopathic arthritis (formerly juvenile rheumatoid arthritis; JIA) in pediatric patients aged 2 years and older. These indications stem from its role as a nonsteroidal anti-inflammatory drug (NSAID) that preferentially inhibits cyclooxygenase-2 (COX-2), reducing prostaglandin synthesis to alleviate symptoms without fully suppressing COX-1-mediated protective effects in the gastrointestinal tract.^[5]^[5]^[1]^[6] The efficacy of meloxicam in OA was demonstrated in a 12-week, double-blind, placebo-controlled study involving 774 patients with knee OA, where doses of 7.5 mg and 15 mg once daily significantly improved pain and physical function compared to placebo (p<0.05), comparable to diclofenac 100 mg daily, with benefits observable from week 2. Post-2000 meta-analyses, including a 2021 network meta-analysis of 192 trials on NSAIDs for OA, have confirmed meloxicam's long-term benefits in reducing pain and improving function, positioning it as comparably effective to other NSAIDs like diclofenac and naproxen while offering a favorable gastrointestinal safety profile at standard doses. For RA and JIA, clinical data support its use in managing chronic inflammation and joint symptoms, with sustained efficacy over months in responsive patients.^[7]^[8] Off-label uses of meloxicam include short-term management of acute pain, gout flares, and ankylosing spondylitis. In gout, it provides rapid relief of inflammatory symptoms during acute attacks, as supported by systematic reviews showing NSAIDs like meloxicam to be effective alternatives to traditional agents such as indomethacin. For ankylosing spondylitis, it is sometimes prescribed to reduce spinal inflammation and pain, though not formally FDA-approved for this condition. Acute pain management, particularly postoperative, has expanded with the 2020 FDA approval of the intravenous formulation Anjeso for moderate-to-severe pain in adults, either alone or combined with non-NSAID analgesics, based on phase 3 trials demonstrating noninferiority to ketorolac in surgical settings.^[9]^[1]^[10]

Dosage and administration in humans

Meloxicam is typically administered orally for the management of osteoarthritis and rheumatoid arthritis in adults. The recommended starting and maintenance dose for osteoarthritis is 7.5 mg once daily, with some patients potentially benefiting from an increase to 15 mg once daily if needed, though the maximum recommended daily dose is 15 mg.^[4] For rheumatoid arthritis, the initial dose is also 7.5 mg once daily, which may be increased to 15 mg once daily for maintenance in patients requiring additional relief.^[4] Dose adjustments are advised for certain populations to minimize risks. In elderly patients, the lowest effective dose should be used due to increased susceptibility to adverse effects, with close monitoring recommended.^[11] For patients with mild to moderate renal impairment, no dose adjustment is necessary, but meloxicam is not recommended in severe renal impairment or in those undergoing dialysis, where the maximum dose is limited to 7.5 mg daily if used.^[4] In mild to moderate hepatic impairment, no adjustment is required, while use in severe hepatic impairment is not recommended due to lack of data.^[4] For pediatric patients aged 2 years and older with juvenile idiopathic arthritis (formerly juvenile rheumatoid arthritis; JIA), the recommended dose is 0.125 mg/kg orally once daily, up to a maximum of 7.5 mg daily; children weighing 60 kg or more may receive a flat dose of 7.5 mg once daily.^[6] Dosing should start at the lowest effective level and be titrated based on response, with therapy limited to the shortest duration consistent with treatment goals to reduce the risk of adverse events.^[4] An intravenous formulation, Anjeso, is available for the management of moderate to severe pain in adults. The recommended dose is 30 mg administered as a single intravenous bolus over at least 15 seconds once daily, typically for up to 7 days or as needed postoperatively, with monitoring for signs of bleeding or other complications.^[12] This route provides an alternative when oral administration is not feasible, such as in perioperative settings.^[12]

Formulations

Meloxicam is available in various oral formulations for human use, primarily as tablets in strengths of 7.5 mg and 15 mg, which are indicated for the symptomatic relief of osteoarthritis and rheumatoid arthritis.^[13] Capsules offer an alternative solid dosage form, typically starting at 5 mg for flexible dosing in osteoarthritis management.^[14] An oral suspension formulation provides 7.5 mg/5 mL, facilitating administration for patients who experience difficulty with solid oral dosage forms, such as children with juvenile idiopathic arthritis or adults with swallowing impairments.^[13] Intravenous administration is possible through Anjeso, a 30 mg/ml meloxicam injection approved by the FDA in February 2020, which allows for rapid onset of action via bolus infusion over 15 seconds, offering a parenteral option for moderate to severe pain when oral routes are not feasible.^[12]^[15] Combination formulations represent innovations in targeted delivery. ZYNRELEF, an extended-release solution combining bupivacaine and meloxicam, was approved by the FDA in May 2021 for direct instillation into surgical sites during soft tissue or orthopedic procedures, providing up to 72 hours of postoperative analgesia by leveraging local anesthetic and anti-inflammatory effects.^[16] Similarly, SYMBRAVO, a fixed-dose oral tablet containing 20 mg meloxicam and 10 mg rizatriptan, received FDA approval in January 2025 for the acute treatment of migraine with or without aura in adults, combining NSAID-mediated inflammation reduction with triptan vasoconstriction for enhanced symptom relief.^[17] All standard meloxicam formulations, including tablets, capsules, and suspensions, maintain stability when stored at controlled room temperature between 20°C and 25°C (68°F to 77°F), protecting against degradation under typical conditions.^[18] Generic meloxicam products have been shown to be bioequivalent to branded versions in multiple pharmacokinetic studies, exhibiting comparable area under the curve and maximum plasma concentration values, thus ensuring equivalent bioavailability and therapeutic efficacy.^[19]^[20]

Contraindications and precautions

In human patients

Meloxicam is contraindicated in patients with known hypersensitivity to meloxicam or other nonsteroidal anti-inflammatory drugs (NSAIDs), as well as those with a history of asthma, urticaria, or other allergic-type reactions precipitated by aspirin or other NSAIDs, due to the risk of severe bronchospasm.^[6] Meloxicam should be used with extreme caution or avoided in individuals with active gastrointestinal (GI) bleeding, a recent history of GI bleeding, or active peptic ulceration, as NSAIDs like meloxicam can exacerbate these conditions leading to serious complications.^[6] Additionally, meloxicam should not be used for perioperative pain management in the setting of coronary artery bypass graft (CABG) surgery, owing to increased cardiovascular risks.^[6] Meloxicam should generally be avoided in patients with severe heart failure (New York Heart Association class IV) unless the benefits outweigh the risks, as it may worsen cardiac function through fluid retention and hemodynamic effects.^[6] Regarding pregnancy, meloxicam use during the first and second trimesters should be avoided unless the potential benefit justifies the risk to the fetus. From 20 to less than 30 weeks of gestation, use only if needed with close fetal monitoring for oligohydramnios; avoid after 30 weeks due to risks of fetal renal dysfunction, oligohydramnios, premature closure of the ductus arteriosus, and potential neonatal complications such as kidney injury.^[21]^[6] Special precautions are necessary for patients with renal or hepatic impairment, where meloxicam use requires close monitoring of renal function, as it can lead to deterioration, particularly in those with advanced renal disease; it is not recommended in severe cases (creatinine clearance <30 mL/min).^[6] Individuals with hypertension or at risk for fluid retention should be monitored for edema and blood pressure elevations, as NSAIDs can exacerbate these issues.^[2] Elderly patients warrant caution and potential dose adjustments, given their higher susceptibility to age-related renal, hepatic, and cardiac impairments that amplify meloxicam's risks.^[2] According to 2023 guidelines from the National Kidney Foundation, meloxicam should be avoided in patients with chronic kidney disease (CKD) stages 3b through 5 to prevent further renal decline.^[22]

In veterinary patients

Meloxicam is contraindicated in veterinary patients across species with known hypersensitivity to the drug, as well as in those with active gastrointestinal ulceration, bleeding disorders, dehydration, or pre-existing renal, hepatic, or cardiovascular impairment, due to the risk of exacerbating these conditions.^[23]^[24] In cats, meloxicam should be avoided in those with chronic kidney disease (CKD) at International Renal Interest Society (IRIS) stage 3 or 4, corresponding to severe renal impairment where glomerular filtration rate is substantially reduced (typically below 25% of normal function), as this increases the risk of acute kidney injury.^[25]^[26] In November 2024, the U.S. FDA added a boxed warning to meloxicam labels for use in cats, noting that repeated administration (additional injectable or oral doses beyond the initial dose) has been associated with acute renal failure and death; additional doses are not recommended.^[27] In dogs, caution is advised in patients with hepatic disease, with regular monitoring of liver enzymes recommended to prevent potential hepatotoxicity.^[24]^[28] Meloxicam poses risks during pregnancy, exhibiting teratogenic effects in rats, including increased rates of abortion, fetal resorptions, growth retardation, and malformations such as limb paralysis and subcutaneous hematomas; embryotoxic effects have also been observed in rabbits at doses as low as 1 mg/kg.^[29]^[30] Consequently, its use is contraindicated in pregnant or lactating animals to avoid potential harm to offspring.^[30] The 2024 International Society of Feline Medicine (ISFM) and American Association of Feline Practitioners (AAFP) consensus guidelines provide guidance for chronic meloxicam use in cats, supporting low-dose administration (e.g., 0.01–0.05 mg/kg PO q24h) in stable IRIS stage 1–2 CKD with close monitoring of renal parameters like creatinine, symmetric dimethylarginine (SDMA), and urine protein:creatinine ratio, based on studies showing no significant decline in glomerular filtration rate.^[25] These updates emphasize hydration status, avoidance in dehydrated or hypotensive cats, and individualized risk assessment to mitigate renal toxicity concerns.^[25]

Adverse effects

Cardiovascular risks

Meloxicam, a nonsteroidal anti-inflammatory drug (NSAID), is associated with 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 or higher doses.^[5] The U.S. Food and Drug Administration (FDA) issued a boxed warning for all prescription NSAIDs, including meloxicam, in 2005, highlighting these cardiovascular risks, with updates in 2015 to emphasize that the danger applies to patients with or without prior heart disease and can emerge within the first weeks of therapy.^[31] Evidence from large-scale studies supports this association. A population-based nested case-control study of over 39,000 individuals found that current use of meloxicam was linked to a 38% increased risk of myocardial infarction, with an adjusted odds ratio of 1.38 (95% CI: 1.17–1.63) compared to remote use.^[32] A Bayesian meta-analysis of individual patient data from nearly 450,000 people reported that all studied NSAIDs, including those similar to meloxicam in selectivity, elevated the risk of acute myocardial infarction within the first week of use, with odds ratios ranging from 1.24 to 1.58 and a dose-dependent effect—for instance, higher daily doses amplified the hazard.^[33] In patients post-myocardial infarction, a nationwide cohort study of over 108,000 individuals indicated that meloxicam conferred a lower relative cardiovascular risk (hazard ratio: 3.03; 95% CI: 1.68–5.47) compared to nonselective NSAIDs like ibuprofen or diclofenac, though absolute risk remained substantially elevated versus no NSAID use.^[34] Patients with pre-existing cardiovascular disease or risk factors, such as hypertension or diabetes, face a higher absolute incidence of these events with meloxicam.^[5] Concurrent use with aspirin may diminish aspirin's cardioprotective effects by competitively inhibiting its antiplatelet activity, potentially exacerbating thrombotic risks in vulnerable individuals.^[35] A meta-analysis of NSAIDs overall estimated a relative risk of 1.14 for major vascular events, underscoring the class-wide concern applicable to meloxicam.^[33] The preferential inhibition of cyclooxygenase-2 (COX-2) by meloxicam contributes to this risk by disrupting the balance between vasodilatory prostacyclin and prothrombotic thromboxane.^[35] For monitoring, guidelines recommend a baseline cardiovascular assessment prior to initiating meloxicam, particularly in at-risk patients, with ongoing vigilance for symptoms such as chest pain, shortness of breath, or sudden weakness; blood pressure should be checked regularly, and the drug discontinued if cardiac symptoms arise.^[5]^[36]

Gastrointestinal risks

Meloxicam, like other nonsteroidal anti-inflammatory drugs (NSAIDs), is associated with an increased risk of serious gastrointestinal adverse events, including ulceration, bleeding, and perforation of the stomach or intestines, which can occur with or without warning symptoms.^[5] In clinical trials involving patients with osteoarthritis, the incidence of complicated upper gastrointestinal events, such as perforations, ulcers, or bleeds, was approximately 0.4% for meloxicam users.^[37] The preferential selectivity of meloxicam for cyclooxygenase-2 (COX-2) over COX-1 contributes to a lower risk of these events compared to non-selective NSAIDs. A meta-analysis of randomized controlled trials demonstrated that meloxicam users experienced fewer perforations, ulcers, and bleeds, with an odds ratio of 0.52 (95% CI: 0.28–0.96) relative to non-selective NSAIDs.^[38] Symptomatic gastrointestinal effects, such as dyspepsia and abdominal pain, occur more commonly, affecting about 7.2% of patients in comparative trials.^[37] Certain patient groups face heightened risks, including the elderly and those with a prior history of peptic ulcers or gastrointestinal bleeding.^[5] To mitigate these risks, co-administration of proton pump inhibitors (PPIs) is recommended for high-risk individuals, as PPIs effectively reduce the incidence of NSAID-induced upper gastrointestinal ulcers and bleeding.^[39] The U.S. Food and Drug Administration includes a boxed warning on meloxicam labeling regarding the potential for serious upper gastrointestinal toxicity.^[5]

Other common and serious effects

Common adverse effects of meloxicam include headache, occurring in 5.5% to 10.2% of patients in clinical trials, dizziness in 1.1% to 3.8%, and rash in 0.6% to 3.0%.^[5] These effects are generally mild and transient, with headache and dizziness reported as common (>1/100 to <1/10) and rash as uncommon (>1/1,000 to <1/100) in post-authorization data.^[40] Serious effects encompass renal impairment, characterized by elevated serum creatinine levels and potential progression to acute renal failure, particularly with long-term use; monitoring of renal function is recommended, especially in at-risk patients.^[5] Hepatotoxicity may manifest as elevations in ALT or AST three or more times the upper limit of normal in approximately 1% of treated patients, with rare instances of severe hepatic injury including fulminant hepatitis and liver failure.^[5] Anaphylactic reactions have been associated with meloxicam, occurring in patients with or without prior hypersensitivity, necessitating immediate medical intervention if symptoms arise.^[5] Meloxicam use during pregnancy after 20 weeks may cause fetal renal dysfunction leading to reduced amniotic fluid (oligohydramnios) and other complications; it is recommended to avoid or limit use to the lowest dose and shortest duration possible.^[5] Rare adverse events include aseptic meningitis, reported in post-marketing surveillance, and Stevens-Johnson syndrome, a potentially life-threatening skin reaction that requires prompt discontinuation of the drug.^[5] Post-marketing reports also document additional events such as interstitial nephritis, jaundice, and toxic epidermal necrolysis.^[5] In elderly patients, the risk of renal toxicity is heightened due to age-related declines in renal function, underscoring the need for cautious use and regular monitoring.^[5]

Drug interactions

Interactions with other medications

Meloxicam, a nonsteroidal anti-inflammatory drug (NSAID), can interact with various medications, potentially leading to increased risks of adverse effects or altered drug efficacy. These interactions often stem from meloxicam's inhibition of prostaglandin synthesis, effects on renal function, or displacement from plasma protein binding sites.^[5] Concomitant use of meloxicam with anticoagulants such as warfarin increases the risk of bleeding due to a synergistic anticoagulant effect. Clinical studies have shown that NSAIDs like meloxicam can enhance the hypoprothrombinemic response to warfarin, necessitating close monitoring of international normalized ratio (INR) levels to prevent hemorrhage. Patients on this combination should be observed for signs of bleeding, and dose adjustments may be required based on INR results.^[5]^[41] When meloxicam is administered with angiotensin-converting enzyme (ACE) inhibitors or angiotensin receptor blockers (ARBs), it may diminish their antihypertensive effects by interfering with renal prostaglandin-mediated vasodilation. This interaction can also exacerbate renal impairment, particularly in elderly patients, those with volume depletion, or preexisting kidney disease, potentially leading to acute kidney injury. Blood pressure and renal function, including serum creatinine and potassium levels, should be monitored regularly in such patients.^[5]^[41] The concurrent use of meloxicam with other NSAIDs or aspirin heightens the risk of additive gastrointestinal toxicity, including ulceration, bleeding, and perforation, without providing additional therapeutic benefits. This is due to the combined inhibition of protective prostaglandins in the gastric mucosa. Concomitant therapy is generally not recommended, and if unavoidable, patients should receive gastrointestinal protective agents and be monitored for symptoms of GI distress. Renal toxicity may also be amplified in susceptible individuals.^[5]^[41] Meloxicam can elevate plasma levels of lithium by reducing its renal clearance, with reported mean increases of approximately 15% in lithium concentrations. This interaction arises partly from NSAID-induced decreases in renal blood flow and glomerular filtration rate. Signs of lithium toxicity, such as tremor or confusion, should be monitored, and lithium levels need regular assessment with possible dose reductions.^[5]^[41] Similarly, meloxicam interacts with methotrexate by displacing it from plasma protein binding sites and inhibiting its renal secretion, leading to higher methotrexate concentrations and increased risk of toxicity, including myelosuppression and renal damage. This effect is more pronounced in patients with renal impairment. Methotrexate levels and signs of toxicity should be closely monitored, and dose adjustments or alternative therapies may be necessary during concurrent use.^[5]^[41] Concomitant use of meloxicam with selective serotonin reuptake inhibitors (SSRIs) may increase the risk of gastrointestinal bleeding. Both NSAIDs and SSRIs can inhibit platelet function and damage the GI mucosa, leading to additive effects. Patients should be monitored for signs of bleeding, especially those with a history of GI disorders.^[5]

Interactions with food and lifestyle factors

Meloxicam can be administered with or without food, as the extent of absorption remains unaffected by meals. However, ingestion following a high-fat meal delays the time to peak plasma concentration (Tmax) to approximately 5-6 hours and may slightly increase peak levels (Cmax) by about 22%, though the overall bioavailability (AUC) is unchanged. Taking meloxicam with food is recommended to help reduce the risk of gastrointestinal upset, a common adverse effect of nonsteroidal anti-inflammatory drugs (NSAIDs).^[13] Concurrent alcohol consumption with meloxicam elevates the risk of gastrointestinal bleeding and ulceration, as alcohol irritates the stomach lining and synergizes with the NSAID's inhibitory effects on mucosal protection. Even moderate intake, such as up to one drink per day, can increase this bleeding risk by approximately 37% in NSAID users. Healthcare guidelines advise limiting or avoiding alcohol during meloxicam therapy to mitigate these hazards, particularly in individuals with a history of gastrointestinal issues.^[13]^[42]^[43] Among lifestyle factors, smoking may compound meloxicam's potential cardiovascular risks, as both tobacco use and NSAIDs independently elevate the likelihood of thrombotic events like myocardial infarction. Adequate hydration is crucial during meloxicam treatment to support renal function, since NSAIDs can impair kidney perfusion, particularly in states of volume depletion. Meloxicam should be avoided or used cautiously in dehydrated individuals, such as during illness, exercise, or hot weather, to prevent acute renal injury.^[1]^[13]

Pharmacology

Mechanism of action

Meloxicam is a nonsteroidal anti-inflammatory drug (NSAID) that primarily exerts its therapeutic effects through selective inhibition of the cyclooxygenase-2 (COX-2) enzyme, with lesser activity against cyclooxygenase-1 (COX-1). This preferential inhibition disrupts the conversion of arachidonic acid to prostaglandin H2 (PGH2), a key precursor in the biosynthesis of proinflammatory prostaglandins such as PGE2 and PGI2. By reducing prostaglandin levels at sites of inflammation, meloxicam alleviates pain, suppresses fever, and mitigates inflammatory responses.^[44] The selectivity of meloxicam for COX-2 over COX-1 is evidenced by in vitro IC50 values of approximately 0.15 μM for COX-2 and 0.99 μM for COX-1, yielding a selectivity ratio of about 6.6:1; other assays report ratios ranging from 10:1 to 30:1 depending on the experimental conditions.^[45]^[46] Meloxicam binds reversibly to the COX active site in a competitive manner with respect to arachidonic acid, utilizing a unique two-water-mediated hydrogen bonding network that interacts with key residues including Arg120, Tyr355, Tyr385, and Ser530. This binding mode allows for efficient occupation of the COX-2 active site while exhibiting reduced affinity for COX-1.^[45]^[44] Compared to other NSAIDs, meloxicam demonstrates greater COX-2 selectivity than diclofenac, which has a ratio of approximately 2:1 to 5:1, but lower selectivity than celecoxib, which achieves ratios of 30:1 or higher. This intermediate selectivity profile contributes to its balanced efficacy and tolerability in treating inflammatory conditions.^[47]^[48]

Pharmacodynamics

Meloxicam exhibits dose-dependent inhibition of prostaglandin E2 (PGE2) production in inflamed tissues through its preferential inhibition of cyclooxygenase-2 (COX-2), which is upregulated during inflammation.^[49] In models of inflammation, meloxicam reduces PGE2 levels in a manner proportional to dose, contributing to its anti-inflammatory effects.^[50] This selective suppression of PGE2 in inflammatory sites helps mitigate pain and swelling without equally affecting constitutive prostaglandin production in non-inflamed areas.^[51] Clinical studies demonstrate that meloxicam reduces key inflammation markers, including C-reactive protein (CRP) and erythrocyte sedimentation rate (ESR), in patients with rheumatoid arthritis.^[51] Similarly, treatment with meloxicam has been associated with reductions in CRP, alongside ESR, in inflammatory arthritic conditions, supporting its role in modulating acute-phase responses.^[52] Regarding analgesic potency, meloxicam is equipotent to naproxen at equi-analgesic doses in managing rheumatoid arthritis symptoms. A six-month double-blind trial showed that meloxicam 7.5 mg once daily provided comparable pain relief and functional improvement to naproxen 750 mg daily, with similar efficacy in reducing disease activity scores.^[53] The COX-2 selectivity of meloxicam results in lower platelet inhibition compared to non-selective NSAIDs, thereby reducing the tendency for bleeding complications. Unlike non-selective agents such as naproxen, which strongly inhibit COX-1 in platelets leading to prolonged thromboxane A2 suppression, meloxicam causes only modest and reversible inhibition of platelet aggregation at therapeutic doses.^[54] This profile contributes to a more favorable gastrointestinal safety margin while maintaining anti-inflammatory benefits.^[55]

Pharmacokinetics

Absorption

Meloxicam is well absorbed after oral administration, with an absolute bioavailability of approximately 89% when compared to intravenous dosing. Following a single oral dose, peak plasma concentrations (Cmax) are typically achieved within 4 to 5 hours under fasted conditions.^[4] The extent of absorption, as measured by the area under the curve (AUC), remains unchanged when meloxicam is taken with food, though the time to maximum concentration (Tmax) is delayed to approximately 6 to 7 hours in the presence of a high-fat meal. This delay does not significantly alter overall exposure, allowing for administration with or without regard to meals.^[4] Intravenous formulations, such as Anjeso, provide immediate absorption, with Tmax occurring at about 0.12 hours post-administration, resulting in rapid achievement of peak plasma levels.^[12] Different oral formulations exhibit comparable absorption profiles; for instance, the oral suspension is bioequivalent to tablets and capsules in terms of bioavailability and pharmacokinetics.^[4]

Distribution

After absorption, meloxicam exhibits a small volume of distribution of approximately 0.13 L/kg, indicating limited distribution into tissues beyond the plasma compartment.^[56] It is highly bound to plasma proteins, with about 99.4% binding primarily to albumin within the therapeutic dose range, which restricts the free fraction available for tissue distribution.^[57] Meloxicam demonstrates good penetration into certain tissues, achieving concentrations in synovial fluid that range from 40% to 50% of plasma levels following a single oral dose; the free fraction in synovial fluid is approximately 2.5 times higher than in plasma due to lower albumin content in this compartment.^[57] In animal studies, meloxicam crosses the placenta, though human placental transfer has not been definitively established.^[58] In special populations such as those with hypoalbuminemia, the free fraction of meloxicam increases, potentially leading to higher unbound concentrations and altered distribution dynamics despite reduced total plasma levels.^[59] With daily dosing, steady-state plasma concentrations of meloxicam are typically reached within 3 to 5 days, reflecting its pharmacokinetic profile after repeated administration.^[60]

Metabolism

Meloxicam undergoes extensive hepatic metabolism primarily through cytochrome P450 enzymes, with CYP2C9 serving as the major contributor and CYP3A4 playing a minor role in its biotransformation.^[61]^[62] The primary pathway involves oxidation of the methyl group at the 5' position, leading to the formation of pharmacologically inactive metabolites, including the major 5'-carboxy meloxicam (accounting for approximately 60% of the dose) and the minor 5'-hydroxymethyl meloxicam (about 9% of the dose).^[61] These metabolites, along with two others (each representing 16% and 4% of the dose), are inactive and do not contribute to the drug's therapeutic effects.^[61] Genetic polymorphisms in the CYP2C9 gene significantly influence meloxicam's metabolism. Individuals with poor metabolizer phenotypes, such as the CYP2C9*1/*13 variant, exhibit substantially reduced enzyme activity, resulting in prolonged drug exposure and an extended elimination half-life of up to approximately 40 hours, compared to the normal range of 15-20 hours in extensive metabolizers.^[63]^[64] This variation can lead to higher plasma concentrations and increased risk of adverse effects, prompting recommendations for alternative therapies in poor metabolizers.^[64] Meloxicam's metabolism is also susceptible to modulation by external factors affecting CYP enzymes. Rifampin, a potent inducer of CYP3A4 and other CYPs, can accelerate meloxicam clearance, thereby decreasing its plasma levels and potentially reducing efficacy.^[65] Conversely, fluconazole, a moderate inhibitor of CYP2C9, impairs meloxicam biotransformation, leading to elevated exposure and a longer half-life, which may necessitate dose adjustments to avoid toxicity.^[65]

Excretion

Meloxicam is primarily eliminated through hepatic metabolism, with the resulting metabolites excreted in approximately equal proportions via the renal and fecal routes. Roughly 45% of the administered dose is recovered in the urine, consisting mainly of inactive metabolites such as the 5'-carboxy and 5'-hydroxymethyl derivatives, while only about 1.6% of the unchanged parent drug appears in the feces and less than 0.2% in the urine. The remaining 53% of the dose is excreted in the feces as metabolites, reflecting the drug's extensive biotransformation prior to elimination.^[65] The elimination half-life of meloxicam in young healthy adults typically ranges from 15 to 20 hours, supporting once-daily dosing regimens. In elderly patients, this half-life is slightly prolonged to approximately 21 hours, accompanied by higher plasma exposure due to age-related reductions in clearance and volume of distribution.^[65]^[60] Total plasma clearance of meloxicam is approximately 8 mL/min (7 to 9 mL/min) in individuals with normal renal function. In patients with renal impairment, clearance is notably reduced, particularly in moderate to severe cases, necessitating caution and potential dose adjustments to avoid accumulation. Meloxicam is minimally removed by dialysis, with hemodialysis patients limited to a maximum daily dose of 7.5 mg.^[66]

History and development

Discovery and synthesis

Meloxicam was developed by the pharmaceutical company Boehringer Ingelheim in 1977 as an enolic acid derivative within the oxicam class of nonsteroidal anti-inflammatory drugs (NSAIDs). The synthesis of meloxicam and related compounds was first detailed in a German patent application filed by Boehringer Ingelheim's subsidiary Thomae GmbH in December 1977 (DE 2756113), with the corresponding U.S. patent (US 4,233,299) granted in 1980 to Boehringer Ingelheim GmbH.^[67]^[68] This patent described the preparation of 4-hydroxy-2H-1,2-benzothiazine-3-carboxamide-1,1-dioxides and their salts, focusing on their potential anti-inflammatory properties through structural modifications to enhance efficacy and safety compared to earlier oxicams like piroxicam. The chemical structure of meloxicam is 4-hydroxy-2-methyl-N-(5-methyl-1,3-thiazol-2-yl)-2H-1,2-benzothiazine-3-carboxamide 1,1-dioxide, featuring a benzothiazine core with a thiazolyl amide substituent that contributes to its selectivity and stability.^[68]^[69] Synthesis typically involves condensation reactions starting from saccharin derivatives, followed by methylation and amidation steps to introduce the methyl and thiazolyl groups, as outlined in the original patent process.^[68] Following patenting, initial pre-clinical studies in the 1980s evaluated meloxicam's anti-inflammatory effects using standard animal models, such as carrageenan-induced paw edema in rats and adjuvant-induced arthritis, demonstrating potent inhibition of inflammation with reduced gastrointestinal irritation relative to traditional NSAIDs.^[70] These tests confirmed its activity at low doses (e.g., 0.3–3 mg/kg in rodents), establishing a foundation for further development. Key milestones included the initiation of first human trials around 1990 to assess safety and pharmacokinetics in healthy volunteers.^[71] By 1994, research highlighted meloxicam's preferential inhibition of cyclooxygenase-2 (COX-2) over COX-1, a property later substantiated in human enzyme assays showing approximately 75-fold selectivity for COX-2 at therapeutic concentrations.^[72]

Clinical trials and approvals

Meloxicam underwent several pivotal clinical trials in the late 1990s to establish its efficacy and safety for treating osteoarthritis (OA) and rheumatoid arthritis (RA). A double-blind, randomized study conducted in 1998 evaluated the safety profile of meloxicam in elderly patients (aged 65 years or older) with OA and comorbid conditions such as controlled hypertension or diabetes, comparing it to other NSAIDs like diclofenac; the study demonstrated comparable efficacy to diclofenac for pain relief and function improvement while showing a favorable gastrointestinal tolerability in this high-risk population.^[73] A pooled analysis of five double-blind, randomized controlled trials involving over 5,000 patients with OA, published in 1998, confirmed that meloxicam at doses of 7.5 mg and 15 mg daily provided significant pain reduction and improved physical function, comparable to standard NSAIDs like diclofenac and piroxicam, with onset of action within 24-48 hours.^[7] These trials supported meloxicam's approval for OA by demonstrating non-inferiority to active comparators in reducing symptoms such as joint pain and stiffness. Regulatory approvals for meloxicam in humans followed closely after these pivotal studies. In Europe, meloxicam tablets (7.5 mg and 15 mg) received initial marketing authorization in 1996 through decentralized procedures for the symptomatic treatment of RA and OA in adults.^[74] In the United States, the FDA approved meloxicam (Mobic) oral tablets on April 13, 2000, for the relief of signs and symptoms of OA at doses of 7.5 mg or 15 mg once daily; approval for RA followed on August 9, 2002, based on additional trials showing sustained efficacy over 12 weeks compared to placebo and naproxen.^[75]^[76] Post-approval developments expanded meloxicam's formulations and indications. The intravenous formulation Anjeso (meloxicam 30 mg) received FDA approval in February 2020, supported by two Phase 3, randomized, double-blind, placebo-controlled trials conducted in 2019, involving patients with moderate-to-severe postoperative pain following bunionectomy or abdominoplasty; these trials showed significant pain reduction (measured by summed pain intensity difference over 48 hours) and decreased opioid consumption compared to placebo, with effects lasting up to 24 hours per dose. Anjeso was discontinued in 2023 following the manufacturer's bankruptcy.^[77]^[78] Although direct head-to-head comparisons were not part of the primary approval data, network meta-analyses have indicated that intravenous meloxicam provides analgesia comparable to ketorolac in postoperative settings while potentially reducing opioid needs.^[79] In January 2021, the FDA approved Qmiiz, an orally disintegrating tablet formulation of meloxicam (7.5 mg and 15 mg), for the treatment of osteoarthritis and rheumatoid arthritis in adults.^[80] Safety-focused trials have further characterized meloxicam's profile, particularly regarding gastrointestinal and cardiovascular risks. A 2004 pooled analysis of 28 clinical trials (including over 24,000 patients) confirmed meloxicam's gastrointestinal safety, reporting a 36% relative reduction in serious upper GI events (e.g., perforations, ulcers, bleeds) compared to nonselective NSAIDs like diclofenac and piroxicam at therapeutic doses.^[81] For cardiovascular outcomes, a 2023 pharmacovigilance study using the FDA Adverse Event Reporting System analyzed disproportionality signals for NSAIDs, finding no significantly elevated risk of myocardial infarction or stroke with meloxicam relative to other COX-2 preferential inhibitors, though overall NSAID class risks were noted in patients with preexisting conditions.^[82] Pediatric extensions were granted based on dedicated trials. In 2005, the FDA approved meloxicam oral suspension (7.5 mg/5 mL) for juvenile idiopathic arthritis (JIA, formerly juvenile RA) in children aged 2 years and older, supported by a 12-week, open-label extension trial in 515 patients showing sustained efficacy (American College of Rheumatology Pediatric 30 response in 73% at week 12) and a safety profile consistent with adults, including mild adverse effects like headache and vomiting in approximately 10% of participants.^[83]

Society and culture

Brand names and availability

Meloxicam is marketed under several brand names globally, with Mobic being the primary brand in the United States for oral formulations, while Anjeso is approved specifically for intravenous use in the US.^[84] In Europe, common brand names include Movalis and Recoxa, often available in tablet, injection, and suppository forms.^[85]^[86] Other international brands encompass a wide range, such as Acticam in Latin America and Aflamid in Mexico, reflecting regional marketing by manufacturers like Boehringer Ingelheim.^[65] Generic meloxicam has been widely available since the key patents for the original Mobic formulation expired, enabling the first generic approvals by the FDA in 2005. This has led to broad accessibility, particularly in generic forms that are prescription-only in most developed markets but available over-the-counter in select countries including India, where it is commonly sold through pharmacies for pain relief.^[87]^[88] In terms of market presence, meloxicam ranked as the 27th most prescribed medication in the United States in 2023, with over 20 million prescriptions dispensed. Globally, the meloxicam market generated approximately USD 1.52 billion in revenue in 2023, driven by demand for arthritis treatments and supported by affordable generic production.^[89] Access remains strong in low-income countries through low-cost generics, enhancing availability for chronic pain management despite varying regulatory requirements.^[90]

Legal status for human use

In the United States, meloxicam is classified as a prescription-only medication (Rx-only) and is not available over-the-counter. The U.S. Food and Drug Administration (FDA) initially approved meloxicam in 2000 for the treatment of osteoarthritis, with subsequent approvals for rheumatoid arthritis and juvenile rheumatoid arthritis. It is not designated as a controlled substance under the Controlled Substances Act.^[13] In the European Union, meloxicam is authorized as a prescription-only medicine, with initial marketing approvals dating back to 1996 in countries such as the United Kingdom and other member states. Regulatory oversight falls under the European Medicines Agency (EMA), but specific authorizations and distribution are managed nationally, leading to variations in availability and prescribing guidelines across EU countries.^[91] Globally, meloxicam is widely approved for human use without major bans or restrictions in significant markets, including Canada (Rx-only), Australia (Schedule 4: Prescription only), and the United Kingdom (POM: Prescription-only medicine). In 2021, the FDA updated the pregnancy labeling for meloxicam and other nonsteroidal anti-inflammatory drugs (NSAIDs) to include warnings against use at or after 20 weeks of gestation due to risks of fetal renal dysfunction leading to oligohydramnios and neonatal renal impairment. No major safety-related recalls of meloxicam have occurred since 2020, though isolated labeling errors involving mispackaged lots have prompted voluntary withdrawals.^[5]^[92]

Veterinary use

Applications in different species

In dogs, meloxicam is a standard therapy for managing osteoarthritis and post-surgical pain, particularly in cases of chronic joint disease where it helps alleviate inflammation and improve mobility.^[93]^[94] A seminal clinical trial reported that meloxicam treatment resulted in significant clinical improvement, including reduced lameness and pain, compared to the placebo group.^[95] In cats, meloxicam is employed for acute pain relief following procedures or injuries, though its use is confined to single doses or brief short-term administration owing to heightened risks of renal failure with repeated exposure.^[27] For cattle, meloxicam serves as an adjunct to antimicrobial therapy in treating clinical mastitis, reducing inflammatory signs and enhancing fertility outcomes such as conception rates; it received initial EU approval for cattle use on January 7, 1998.^[96]^[97] In horses, the drug addresses lameness from musculoskeletal conditions, demonstrating efficacy in reducing asymmetry in movement and supporting recovery in affected animals.^[98]^[99] Among exotic species, meloxicam is utilized for arthritis in captive primates, such as chimpanzees, where it aids in managing mobility impairments and chronic joint pain without notable preferences over alternative analgesics in self-administration paradigms.^[100]

Species-specific dosing and safety

In dogs, meloxicam is typically administered at an initial dose of 0.2 mg/kg body weight orally or subcutaneously on the first day of treatment, followed by a maintenance dose of 0.1 mg/kg orally once daily.^[101] This regimen provides effective analgesia for conditions such as osteoarthritis and postoperative pain, with a high safety margin; in a six-month target animal safety study, doses up to five times the recommended amount showed no significant clinical adverse effects.^[102] However, renal function should be monitored in all dogs, particularly those with pre-existing conditions, as nonsteroidal anti-inflammatory drugs like meloxicam can pose risks of nephrotoxicity if dehydration or hypovolemia occurs.^[103] In cats, the standard dosing begins with a single subcutaneous injection of 0.3 mg/kg body weight for perioperative pain management, followed by an oral maintenance dose of 0.05 mg/kg once daily if needed for up to four days.^[104] The 2024 European Medicines Agency guidelines emphasize limiting use to acute conditions due to the risk of acute renal failure with repeated administration, and the U.S. Food and Drug Administration carries a boxed warning against additional doses after the initial injection.^[27] Renal monitoring is essential in cats, as they are particularly susceptible to kidney injury from nonsteroidal anti-inflammatory drugs, especially in those with underlying renal disease.^[103] For cattle, meloxicam is given as a single subcutaneous or intravenous dose of 0.5 mg/kg body weight to alleviate pain associated with procedures like dehorning.^[101] In horses, the initial dose is 0.6 mg/kg intravenously, with potential maintenance at 0.3 mg/kg orally once daily for up to five days for musculoskeletal disorders.^[101] Across these species, renal function monitoring is recommended to prevent toxicity, particularly in dehydrated animals.^[105] For food-producing animals like cattle, a withdrawal period of 15 days for meat and offal and 5 days for milk must be observed to ensure residue levels remain below maximum residue limits.^[101]

Regulatory status

In the United States, the Food and Drug Administration (FDA), through its Center for Veterinary Medicine (CVM), approved meloxicam under the brand name Metacam for the control of pain and inflammation associated with osteoarthritis in dogs on November 12, 2003.^[106] For cats, the FDA approved a single 0.3 mg/kg subcutaneous injection of meloxicam for the alleviation of postoperative pain following orthopedic surgery, ovariohysterectomy, or castration on October 28, 2004, but repeated doses or oral administration remain extra-label uses with a boxed warning highlighting risks of acute renal failure and death.^[27]^[107] As of 2024, no FDA approval exists for long-term use in cats, though ongoing professional discussions emphasize cautious extra-label application with monitoring.^[108] In the European Union, the European Medicines Agency (EMA) first authorized meloxicam (Metacam) for veterinary use on January 7, 1998, initially for cattle, with subsequent extensions to dogs, cats, pigs, horses, and other species for indications including inflammation and pain relief in musculoskeletal disorders.^[109] For cats, EMA-approved low-dose oral suspensions (0.5 mg/ml) permit long-term use for chronic conditions like osteoarthritis, unlike stricter single-dose limitations in some other regions.^[101] In January 2024, the EMA's Committee for Veterinary Medicinal Products (CVMP) issued a positive opinion for variations to Metacam's authorization, supporting continued multi-species applications without new restrictions on feline use.^[110] Meloxicam is approved for veterinary use in Canada and Australia for dogs and cats, including long-term oral administration in cats for pain management, with approvals dating back to the early 2000s and extensions for species like sheep in 2016 via joint reviews.^[23] In regions with food-producing animals, such as the EU and parts of North America, meloxicam is permitted in cattle, pigs, and sheep but requires mandatory withdrawal periods to prevent residue violations; for instance, the EU mandates 15 days for meat and offal in cattle and 5 days in pigs, with non-compliance effectively prohibiting use near slaughter.^[111] Recent updates include the 2024 International Society of Feline Medicine (ISFM) and American Association of Feline Practitioners (AAFP) consensus guidelines on long-term NSAID use in cats, which endorse meloxicam as a viable option for chronic pain when monitored, as reported by the American Veterinary Medical Association (AVMA).^[112] These guidelines build on prior AVMA-supported frameworks, emphasizing species-specific safety in companion animals.^[113]

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In Europe it is marketed under the brand names Movalis, Melox, and Recoxa. In the U.S. it is generally marketed under the brand name Mobic, in Canada as Mobicox ...<|separator|>
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Meloxicam Tablet - Melorise 7.5 Tablet Latest Price, Manufacturers ...
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The global Meloxicam market reached a valuation of approximately USD 1.52 billion in 2023 ... Get Discount On The Purchase of the Global Meloxicam Market Size And ...
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METACAM® (meloxicam oral suspension) for Osteoarthritis
METACAM (meloxicam oral suspension) is indicated for the control of pain and inflammation associated with osteoarthritis (OA) in dogs.
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Does meloxicam provide adequate pain management as a post ...
May 2, 2020 · The results from the study indicate that meloxicam is an effective post-operative analgesic for canine patients undergoing an ovariohysterectomy ...Results · Conclusion · Literature review · Methodology
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Nov 26, 2024 · However, after reviewing numerous reports of side effects of meloxicam in cats, FDA identified many cases of sudden kidney failure (also called ...
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pets with bloody stools or vomit · pets that have pre-existing kidney or liver conditions · pets that have loss of appetite · pets that are taking other NSAIDs ( ...
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[PDF] Metacam, meloxicam - European Commission
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[PDF] Meloxoral, INN-meloxicam
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[PDF] Meloxicam - Meloxidolor - European Commission
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2022 AAHA Pain Management Guidelines for Dogs and Cats
Feb 24, 2022 · These guidelines offer a comprehensive framework for veterinary professionals to deliver compassionate and effective pain management.