Elevations of ALT or AST (three or more times the upper limit of normal [ULN]) have been reported in approximately 1% of NSAID-treated patients in clinical trials. In addition, rare, sometimes fatal, cases of severe hepatic injury, including fulminant hepatitis, liver necrosis, and hepatic failure have been reported.
Elevations of ALT or AST (less than three times ULN) may occur in up to 15% of patients treated with NSAIDs including meloxicam.
Inform patients of the warning signs and symptoms of hepatotoxicity (e.g., nausea, fatigue, lethargy, diarrhea, pruritus, jaundice, right upper quadrant tenderness, and “flu-like” symptoms). If clinical signs and symptoms consistent with liver disease develop, or if systemic manifestations occur (e.g., eosinophilia, rash, etc.), discontinue meloxicam immediately, and perform a clinical evaluation of the patient [see USE IN SPECIFIC POPULATIONS (8.6) and CLINICAL PHARMACOLOGY (12.3)].
NSAIDs, including meloxicam, can lead to new onset or worsening of preexisting hypertension, either of which may contribute to the increased incidence of CV events. Patients taking angiotensin converting enzyme (ACE) inhibitors, thiazide diuretics, or loop diuretics may have impaired response to these therapies when taking NSAIDs [see DRUG INTERACTIONS (7)].
Monitor blood pressure (BP) during the initiation of NSAID treatment and throughout the course of therapy.
The Coxib and traditional NSAID Trialists’ Collaboration meta-analysis of randomized controlled trials demonstrated an approximately two-fold increase in hospitalizations for heart failure in COX-2 selective-treated patients and nonselective NSAID-treated patients compared to placebo-treated patients. In a Danish National Registry study of patients with heart failure, NSAID use increased the risk of MI, hospitalization for heart failure, and death.
Additionally, fluid retention and edema have been observed in some patients treated with NSAIDs. Use of meloxicam may blunt the CV effects of several therapeutic agents used to treat these medical conditions (e.g., diuretics, ACE inhibitors, or angiotensin receptor blockers [ARBs]) [see DRUG INTERACTIONS (7)].
Avoid the use of meloxicam in patients with severe heart failure unless the benefits are expected to outweigh the risk of worsening heart failure. If meloxicam is used in patients with severe heart failure, monitor patients for signs of worsening heart failure.
Long-term administration of NSAIDs, including meloxicam, has resulted in renal papillary necrosis, renal insufficiency, acute renal failure, and other renal injury.
Renal toxicity has also been seen in patients in whom renal prostaglandins have a compensatory role in the maintenance of renal perfusion. In these patients, administration of an NSAID may cause a dose-dependent reduction in prostaglandin formation and, secondarily, in renal blood flow, which may precipitate overt renal decompensation. Patients at greatest risk of this reaction are those with impaired renal function, dehydration, hypovolemia, heart failure, liver dysfunction, those taking diuretics and ACE inhibitors or ARBs, and the elderly. Discontinuation of NSAID therapy is usually followed by recovery to the pretreatment state.
The renal effects of meloxicam may hasten the progression of renal dysfunction in patients with preexisting renal disease. Because some meloxicam metabolites are excreted by the kidney, monitor patients for signs of worsening renal function.
Correct volume status in dehydrated or hypovolemic patients prior to initiating meloxicam. Monitor renal function in patients with renal or hepatic impairment, heart failure, dehydration, or hypovolemia during use of meloxicam [see DRUG INTERACTIONS (7)].
No information is available from controlled clinical studies regarding the use of meloxicam in patients with advanced renal disease. Avoid the use of meloxicam in patients with advanced renal disease unless the benefits are expected to outweigh the risk of worsening renal function. If meloxicam is used in patients with advanced renal disease, monitor patients for signs of worsening renal function [see CLINICAL PHARMACOLOGY (12.3)].
Increases in serum potassium concentration, including hyperkalemia, have been reported with use of NSAIDs, even in some patients without renal impairment. In patients with normal renal function, these effects have been attributed to a hyporeninemic-hypoaldosteronism state.
Meloxicam has been associated with anaphylactic reactions in patients with and without known hypersensitivity to meloxicam and in patients with aspirin-sensitive asthma [see CONTRAINDICATIONs (4) and WARNINGS AND PRECAUTIONS (5.8)].
Seek emergency help if an anaphylactic reaction occurs.
A subpopulation of patients with asthma may have aspirin-sensitive asthma which may include chronic rhinosinusitis complicated by nasal polyps; severe, potentially fatal bronchospasm; and/or intolerance to aspirin and other NSAIDs. Because cross-reactivity between aspirin and other NSAIDs has been reported in such aspirin-sensitive patients, meloxicam is contraindicated in patients with this form of aspirin sensitivity [see CONTRAINDICATIONS (4)]. When meloxicam is used in patients with preexisting asthma (without known aspirin sensitivity), monitor patients for changes in the signs and symptoms of asthma.
NSAIDs, including meloxicam, can cause serious skin adverse reactions such as exfoliative dermatitis, Stevens-Johnson Syndrome (SJS), and toxic epidermal necrolysis (TEN), which can be fatal. These serious events may occur without warning. Inform patients about the signs and symptoms of serious skin reactions, and to discontinue the use of meloxicam at the first appearance of skin rash or any other sign of hypersensitivity. Meloxicam is contraindicated in patients with previous serious skin reactions to NSAIDs [see CONTRAINDICATIONS (4)].
Meloxicam may cause premature closure of the fetal ductus arteriosus. Avoid use of NSAIDs, including meloxicam, in pregnant women starting at 30 weeks of gestation (third trimester) [see USE IN SPECIFIC POPULATIONS (8.1)].
Anemia has occurred in NSAID-treated patients. This may be due to occult or gross blood loss, fluid retention, or an incompletely described effect on erythropoiesis. If a patient treated with meloxicam has any signs or symptoms of anemia, monitor hemoglobin or hematocrit.
NSAIDs, including meloxicam, may increase the risk of bleeding events. Co-morbid conditions such as coagulation disorders or concomitant use of warfarin, other anticoagulants, antiplatelet agents (e.g., aspirin), serotonin reuptake inhibitors (SSRIs) and serotonin norepinephrine reuptake inhibitors (SNRIs) may increase this risk. Monitor these patients for signs of bleeding [see DRUG INTERACTIONS (7)].
The pharmacological activity of meloxicam in reducing inflammation, and possibly fever, may diminish the utility of diagnostic signs in detecting infections.
Because serious GI bleeding, hepatotoxicity, and renal injury can occur without warning symptoms or signs, consider monitoring patients on long-term NSAID treatment with a CBC and a chemistry profile periodically [see WARNINGS AND PRECAUTIONS (5.2, 5.3, 5.6)].
The following adverse reactions are discussed in greater detail in other sections of the labeling:
- Cardiovascular Thrombotic Events [see BOXED WARNING and WARNINGS AND PRECAUTIONS (5.1)]
- GI Bleeding, Ulceration, and Perforation [see BOXED WARNING and WARNINGS AND PRECAUTIONS (5.2)]
- Hepatotoxicity [see WARNINGS AND PRECAUTIONS (5.3)]
- Hypertension [see WARNINGS AND PRECAUTIONS (5.4)]
- Heart Failure and Edema [see WARNINGS AND PRECAUTIONS (5.5)]
- Renal Toxicity and Hyperkalemia [see WARNINGS AND PRECAUTIONS (5.6)]
- Anaphylactic Reactions [see WARNINGS AND PRECAUTIONS (5.7)]
- Serious Skin Reactions [see WARNINGS AND PRECAUTIONS (5.9)]
- Hematologic Toxicity [see WARNINGS AND PRECAUTIONS (5.11)]
Because clinical trials are conducted under widely varying conditions, adverse reaction rates observed in the clinical trials of a drug cannot be directly compared to rates in the clinical trials of another drug and may not reflect the rates observed in practice.
Osteoarthritis and Rheumatoid Arthritis:
The meloxicam Phase 2/3 clinical trial database includes 10,122 OA patients and 1012 RA patients treated with meloxicam 7.5 mg/day, 3505 OA patients and 1351 RA patients treated with meloxicam 15 mg/day. Meloxicam at these doses was administered to 661 patients for at least 6 months and to 312 patients for at least one year. Approximately 10,500 of these patients were treated in ten placebo- and/or active-controlled osteoarthritis trials and 2363 of these patients were treated in ten placebo- and/or active-controlled rheumatoid arthritis trials. Gastrointestinal (GI) adverse events were the most frequently reported adverse events in all treatment groups across meloxicam trials.
A 12-week multicenter, double-blind, randomized trial was conducted in patients with osteoarthritis of the knee or hip to compare the efficacy and safety of meloxicam with placebo and with an active control. Two 12-week multicenter, double-blind, randomized trials were conducted in patients with rheumatoid arthritis to compare the efficacy and safety of meloxicam with placebo.
Table 1a depicts adverse events that occurred in ≥2% of the meloxicam treatment groups in a 12-week placebo- and active-controlled osteoarthritis trial.
Table 1b depicts adverse events that occurred in ≥2% of the meloxicam treatment groups in two 12-week placebo-controlled rheumatoid arthritis trials.
|Placebo||Meloxicam 7 . 5 mg daily||Meloxicam 15 mg daily||Diclofenac 100 mg daily|
|No . of Patients||157||154||156||153|
|Body as a Whole|
|Central and Peripheral Nervous System|
|Upper respiratory tract infection||1.9||3.2||1.9||3.3|
|Placebo||Meloxicam 7 . 5 mg daily||Meloxicam 15 mg daily|
|No . of Patients||469||481||477|
|Abdominal pain NOS *||0.6||2.9||2.3|
|Dyspeptic signs and symptoms †||3.8||5.8||4.0|
|General Disorders and Administration Site Conditions|
|Influenza-like illness *||2.1||2.9||2.3|
|Infection and Infestations|
|Upper respiratory tract infections-pathogen class unspecified †||4.1||7.0||6.5|
|Musculoskeletal and Connective Tissue Disorders|
|Joint related signs and symptoms †||1.9||1.5||2.3|
|Nervous System Disorders|
|Headaches NOS *||6.4||6.4||5.5|
|Skin and Subcutaneous Tissue Disorders|
|Rash NOS *||1.7||1.0||2.1|
The adverse events that occurred with meloxicam in ≥2% of patients treated short-term (4 to 6 weeks) and long-term (6 months) in active-controlled osteoarthritis trials are presented in Table 2.
|4 to 6 Weeks Controlled Trials||6 Month Controlled Trials|
|Meloxicam 7 . 5 mg daily||Meloxicam 15 mg daily||Meloxicam 7 . 5 mg daily||Meloxicam 15 mg daily|
|No . of Patients||8955||256||169||306|
|Body as a Whole|
|Central and Peripheral Nervous System|
|Upper respiratory tract infection||0.2||0.0||8.3||7.5|
|Urinary tract infection||0.3||0.4||4.7||6.9|
Higher doses of meloxicam (22.5 mg and greater) have been associated with an increased risk of serious GI events; therefore, the daily dose of meloxicam should not exceed 15 mg.
Pauciarticular and Polyarticular Course Juvenile Rheumatoid Arthritis (JRA):
Three hundred and eighty-seven patients with pauciarticular and polyarticular course JRA were exposed to meloxicam with doses ranging from 0.125 to 0.375 mg/kg per day in three clinical trials. These studies consisted of two 12-week multicenter, double-blind, randomized trials (one with a 12-week open-label extension and one with a 40-week extension) and one 1-year open-label PK study. The adverse events observed in these pediatric studies with meloxicam were similar in nature to the adult clinical trial experience, although there were differences in frequency. In particular, the following most common adverse events, abdominal pain, vomiting, diarrhea, headache, and pyrexia, were more common in the pediatric than in the adult trials. Rash was reported in seven (<2%) patients receiving meloxicam. No unexpected adverse events were identified during the course of the trials. The adverse events did not demonstrate an age or gender-specific subgroup effect.
The following is a list of adverse drug reactions occurring in <2% of patients receiving meloxicam in clinical trials involving approximately 16,200 patients.
|Body as a Whole||allergic reaction, face edema, fatigue, fever, hot flushes, malaise, syncope, weight decrease, weight increase|
|Cardiovascular||angina pectoris, cardiac failure, hypertension, hypotension, myocardial infarction, vasculitis|
|Central and Peripheral Nervous System||convulsions, paresthesia, tremor, vertigo|
|Gastrointestinal||colitis, dry mouth, duodenal ulcer, eructation, esophagitis, gastric ulcer, gastritis, gastroesophageal reflux, gastrointestinal hemorrhage, hematemesis, hemorrhagic duodenal ulcer, hemorrhagic gastric ulcer, intestinal perforation, melena, pancreatitis, perforated duodenal ulcer, perforated gastric ulcer, stomatitis ulcerative|
|Heart Rate and Rhythm||arrhythmia, palpitation, tachycardia|
|Hematologic||leukopenia, purpura, thrombocytopenia|
|Liver and Biliary System||ALT increased, AST increased, bilirubinemia, GGT increased, hepatitis|
|Metabolic and Nutritional||dehydration|
|Psychiatric||abnormal dreaming, anxiety, appetite increased, confusion, depression, nervousness, somnolence|
|Respiratory||asthma, bronchospasm, dyspnea|
|Skin and Appendages||alopecia, angioedema, bullous eruption, photosensitivity reaction, pruritus, sweating increased, urticaria|
|Special Senses||abnormal vision, conjunctivitis, taste perversion, tinnitus|
|Urinary System||albuminuria, BUN increased, creatinine increased, hematuria, renal failure|
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