Artrozan^® (Tablets, Solution) Instructions for Use

ATC Code

M01AC06 (Meloxicam)

Active Substance

Meloxicam (Rec.INN registered by WHO)

Clinical-Pharmacological Group

NSAID. Selective COX-2 inhibitor

Pharmacotherapeutic Group

NSAID

Pharmacological Action

NSAID, an enolic acid derivative, has anti-inflammatory, analgesic, and antipyretic effects.

The mechanism of the anti-inflammatory action of meloxicam consists in its ability to inhibit the synthesis of prostaglandins, known mediators of inflammation.

Meloxicam in vivo inhibits the synthesis of prostaglandins at the site of inflammation to a greater extent than in the gastric mucosa or kidneys. These differences are associated with more selective inhibition of COX-2 compared to COX-1. It is believed that inhibition of COX-2 provides the therapeutic actions of NSAIDs, whereas inhibition of the constantly present isoenzyme COX-1 may be responsible for side effects from the stomach and kidneys. The selectivity of meloxicam for COX-2 has been confirmed in various test systems, both in vitro and in vivo. The selective ability of meloxicam to inhibit COX-2 was demonstrated using human whole blood in vitro as a test system. It was found that Meloxicam (at doses of 7.5 mg and 15 mg) more actively inhibited COX-2, exerting a greater inhibitory effect on the production of prostaglandin E₂ stimulated by lipopolysaccharide (a reaction controlled by COX-2) than on the production of thromboxane involved in the blood clotting process (a reaction controlled by COX-1). These effects were dose-dependent.

Ex vivo studies have shown that Meloxicam (at doses of 7.5 mg and 15 mg) does not affect platelet aggregation and bleeding time.

In clinical studies, gastrointestinal side effects overall occurred less frequently with meloxicam at doses of 7.5 and 15 mg than with other NSAIDs with which it was compared. This difference in the frequency of gastrointestinal side effects is mainly due to the fact that phenomena such as dyspepsia, vomiting, nausea, and abdominal pain were observed less frequently with meloxicam. The frequency of perforations in the upper gastrointestinal tract, ulcers, and bleeding associated with the use of meloxicam was low and dose-dependent.

Pharmacokinetics

Meloxicam is well absorbed from the gastrointestinal tract, as evidenced by its high absolute bioavailability (90%) after oral administration. After a single use of meloxicam, C_max in plasma is reached within 5-6 hours. Concurrent intake of food and inorganic antacids does not alter absorption. When taken orally (at doses of 7.5 and 15 mg), the concentration of meloxicam is proportional to the dose. Steady-state pharmacokinetics are achieved within 3-5 days. The range of differences between C_max and C_min of meloxicam after its administration once a day is relatively small and is 0.4-1.0 µg/ml when using a dose of 7.5 mg, and when using a dose of 15 mg – 0.8-2.0 µg/ml (the values of C_min and C_max at steady state are given, respectively), although values outside this range have also been noted. C_max in plasma at steady state is reached 5-6 hours after oral administration.

Meloxicam is highly bound to plasma proteins, mainly albumin (99%). It penetrates into the synovial fluid, the concentration in the synovial fluid is approximately 50% of the plasma concentration. V_d after multiple oral administration of meloxicam (at doses from 7.5 mg to 15 mg) is about 16 L, with a coefficient of variation from 11 to 32%. Interindividual differences range from 7-20%.

Meloxicam is almost completely metabolized in the liver to form 4 pharmacologically inactive derivatives. The main metabolite, 5′-carboxymeloxicam (60% of the dose), is formed by oxidation of an intermediate metabolite, 5′-hydroxymethylmeloxicam, which is also excreted, but to a lesser extent (9% of the dose). In vitro studies have shown that the isoenzyme CYP2C9 plays an important role in this metabolic transformation, with the isoenzyme CYP3A4 having additional significance. Peroxidase, whose activity probably varies individually, is involved in the formation of two other metabolites (constituting 16% and 4% of the dose, respectively).

It is excreted equally through the intestine and kidneys, mainly in the form of metabolites. Less than 5% of the daily dose is excreted unchanged in the feces; in urine, Meloxicam is found only in trace amounts unchanged. The average T_1/2 of meloxicam varies from 13 to 25 hours. Plasma clearance averages 7-12 ml/min after a single use.

Indications

Symptomatic treatment: osteoarthritis (arthrosis, degenerative joint diseases), incl. with a pain component; rheumatoid arthritis; ankylosing spondylitis; other inflammatory and degenerative diseases of the musculoskeletal system, such as arthropathies, dorsopathies (for example, sciatica, low back pain, shoulder periarthritis), accompanied by pain.

ICD codes

Dosage Regimen

Tablets

It is set individually, depending on the intensity of pain and the severity of the inflammatory process. It is prescribed orally at a dose of 7.5-15 mg/day; the maximum dose is 15 mg/day.

Solution

Intramuscular administration is indicated in the first 2-3 days of treatment. Subsequently, treatment is continued using oral forms. The recommended dose is 7.5 or 15 mg once a day, depending on the intensity of pain and the severity of the inflammatory process. Since the potential risk of adverse reactions depends on the dose and duration of treatment, the lowest effective doses and the shortest possible course should be used.

In patients with severe renal failure on hemodialysis, the dose should not exceed 7.5 mg/day.

Adverse Reactions

From the hematopoietic system uncommon – anemia; rare – leukopenia, thrombocytopenia, changes in blood cell counts, including changes in the leukocyte formula.

From the immune system uncommon – immediate hypersensitivity reactions; frequency not established – anaphylactic shock, anaphylactoid reactions.

Mental disorders rare – mood changes; frequency not established – confusion, disorientation.

From the nervous system common – headache; uncommon – dizziness, drowsiness.

From the sensory organs uncommon – vertigo; rare – conjunctivitis, visual disturbances, including blurred vision, tinnitus.

From the cardiovascular system uncommon – increased blood pressure, feeling of “flushing”; rare – palpitations.

From the respiratory system rare – bronchial asthma in patients allergic to acetylsalicylic acid and other NSAIDs.

From the digestive system common – abdominal pain, dyspepsia, diarrhea, nausea, vomiting; uncommon – occult or overt gastrointestinal bleeding, gastritis, stomatitis, constipation, flatulence, belching; rare – gastroduodenal ulcers, colitis, esophagitis; very rare – gastrointestinal perforation.

From the liver and biliary tract uncommon – transient changes in liver function parameters (e.g., increased activity of transaminases or bilirubin concentration); very rare – hepatitis.

From the skin and subcutaneous tissues uncommon – angioedema, pruritus, skin rash; rare – toxic epidermal necrolysis, Stevens-Johnson syndrome, urticaria; very rare – bullous dermatitis, erythema multiforme; frequency not established – photosensitivity.

From the urinary system uncommon – changes in renal function parameters (increased serum creatinine and/or urea concentration), urination disorders, including acute urinary retention; very rare – acute renal failure.

From the reproductive system uncommon – delayed ovulation; frequency not established – infertility in women.

Other: uncommon – edema.

Concomitant use with drugs that suppress bone marrow (e.g., methotrexate) may provoke cytopenia.

Gastrointestinal bleeding, ulcer, or perforation can be fatal.

As with other NSAIDs, the possibility of interstitial nephritis, glomerulonephritis, renal medullary necrosis, and nephrotic syndrome cannot be ruled out.

Contraindications

Hypersensitivity to meloxicam; hypersensitivity (incl. to other NSAIDs); complete or incomplete combination of bronchial asthma, recurrent polyposis of the nose or paranasal sinuses, angioedema or urticaria caused by intolerance to acetylsalicylic acid or other NSAIDs due to the existing probability of cross-sensitivity (incl. in history); erosive and ulcerative lesions of the stomach and duodenum in the acute stage or recently suffered; inflammatory bowel diseases (Crohn’s disease or ulcerative colitis in the acute stage); severe hepatic and heart failure; severe renal failure (if hemodialysis is not performed, CrCl <30 ml/min, as well as with confirmed hyperkalemia); active liver disease; active gastrointestinal bleeding, recently suffered cerebrovascular bleeding or established diagnosis of blood clotting disorders; concomitant therapy with anticoagulants, because there is a risk of intramuscular hematoma formation; therapy of perioperative pain during coronary artery bypass surgery; pregnancy; lactation period (breastfeeding); children under 12 years of age.

With caution

History of gastrointestinal diseases (presence of Helicobacter pylori infection); congestive heart failure; renal failure (CrCl 30-60 ml/min); coronary artery disease; cerebrovascular diseases; dyslipidemia/hyperlipidemia; diabetes mellitus; concomitant therapy with the following drugs: anticoagulants, oral glucocorticosteroids, antiplatelet agents, selective serotonin reuptake inhibitors; peripheral arterial diseases; elderly age; long-term use of NSAIDs; smoking; frequent alcohol consumption.

Use in Pregnancy and Lactation

Contraindicated for use during pregnancy and breastfeeding.

Use in Hepatic Impairment

Contraindicated for use in severe hepatic insufficiency, active liver disease.

In patients with (compensated) liver cirrhosis, dose adjustment is not required.

Use in Renal Impairment

Contraindicated for use in severe renal failure (if hemodialysis is not performed, CrCl <30 ml/min, as well as with confirmed hyperkalemia).

Use with caution in renal failure (CrCl 30-60 ml/min).

Pediatric Use

Contraindicated in children under 12 years of age.

Geriatric Use

Should be used with caution in elderly patients.

Special Precautions

Patients with gastrointestinal diseases require regular monitoring. If ulcerative gastrointestinal lesions or gastrointestinal bleeding occur, Meloxicam should be discontinued.

Gastrointestinal ulcers, perforation, or bleeding can occur at any time during NSAID use, both in the presence of warning symptoms or a history of serious gastrointestinal complications and in their absence. The consequences of these complications are generally more serious for the elderly.

Serious skin reactions such as exfoliative dermatitis, Stevens-Johnson syndrome, and toxic epidermal necrolysis may develop with the use of meloxicam. Therefore, special attention should be paid to patients reporting the development of adverse events involving the skin and mucous membranes, as well as hypersensitivity reactions to the drug, especially if such reactions were observed during previous courses of treatment. The development of such reactions is generally observed within the first month of treatment. If the first signs of a skin rash, changes in the mucous membranes, or other signs of hypersensitivity appear, the possibility of discontinuing meloxicam should be considered.

Cases of an increased risk of serious cardiovascular thrombosis, myocardial infarction, and angina attack, possibly fatal, have been described with NSAID use. This risk increases with long-term use of the drug, as well as in patients with a history of the aforementioned diseases and those predisposed to such diseases.

NSAIDs inhibit the synthesis of prostaglandins in the kidneys, which are involved in maintaining renal perfusion. The use of NSAIDs in patients with reduced renal blood flow or reduced circulating blood volume may lead to decompensation of latent renal failure. After discontinuation of NSAIDs, renal function usually returns to baseline. Patients at greatest risk for developing this reaction are the elderly, patients who are dehydrated, have congestive heart failure, liver cirrhosis, nephrotic syndrome, or acute renal dysfunction, patients concurrently taking diuretics, ACE inhibitors, angiotensin II receptor antagonists, and patients who have undergone major surgical procedures leading to hypovolemia. In such patients, diuresis and renal function should be carefully monitored at the beginning of therapy.

The use of NSAIDs together with diuretics may lead to retention of sodium, potassium, and water, as well as a reduction in the natriuretic effect of diuretics. As a result, in predisposed patients, signs of heart failure or arterial hypertension may worsen. Therefore, careful monitoring of the condition of such patients is necessary, as well as maintaining adequate hydration.

Renal function should be investigated before starting treatment. In case of combination therapy, renal function should also be monitored.

When using meloxicam (as well as most other NSAIDs), episodic increases in serum transaminase activity or other liver function parameters are possible. In most cases, this increase was small and transient. If the detected changes are significant or do not decrease over time, Meloxicam should be discontinued and the identified laboratory changes should be monitored.

Weakened or debilitated patients may tolerate adverse events less well, so such patients should be carefully monitored.

Like other NSAIDs, Meloxicam may mask the symptoms of an underlying infectious disease.

As an agent that inhibits COX/prostaglandin synthesis, Meloxicam may affect fertility, and therefore it is not recommended for women having difficulty conceiving. In women undergoing examination for this reason, discontinuation of meloxicam is recommended.

In patients with mild to moderate renal impairment (CrCl>25 ml/min), dose adjustment is not required.

In patients with (compensated) liver cirrhosis, dose adjustment is not required.

Effect on ability to drive vehicles and operate machinery

When driving a car and working with machinery, the possibility of developing dizziness, drowsiness, visual disturbances, or other disorders of the central nervous system should be taken into account. During the treatment period, patients must exercise caution when driving vehicles and engaging in other potentially hazardous activities that require increased concentration and speed of psychomotor reactions.

Drug Interactions

Other inhibitors of prostaglandin synthesis, including glucocorticoids and salicylates – simultaneous use with meloxicam increases the risk of gastrointestinal ulcers and gastrointestinal bleeding (due to synergy of action). Concurrent use with other NSAIDs is not recommended.

Oral anticoagulants, systemically administered heparin, thrombolytic agents – simultaneous use with meloxicam increases the risk of bleeding. In case of simultaneous use, careful monitoring of the blood coagulation system is necessary.

Antiplatelet drugs, serotonin reuptake inhibitors – simultaneous use with meloxicam increases the risk of bleeding due to inhibition of platelet function. In case of simultaneous use, careful monitoring of the blood coagulation system is necessary.

Lithium preparations – NSAIDs increase plasma lithium levels by reducing its renal excretion. Simultaneous use of meloxicam with lithium preparations is not recommended. If simultaneous use is necessary, careful monitoring of plasma lithium concentration is recommended throughout the course of lithium preparations.

Methotrexate – NSAIDs reduce the renal secretion of methotrexate, thereby increasing its plasma concentration. Simultaneous use of meloxicam and methotrexate (at a dose of more than 15 mg per week) is not recommended. In case of simultaneous use, careful monitoring of renal function and blood count is necessary. Meloxicam may enhance the hematological toxicity of methotrexate, especially in patients with impaired renal function.

Diuretics – the use of NSAIDs while taking diuretics in the case of patient dehydration is associated with a risk of developing acute renal failure.

Antihypertensive agents (beta-blockers, ACE inhibitors, vasodilators, diuretics). NSAIDs reduce the effect of antihypertensive agents due to the inhibition of prostaglandins, which have vasodilating properties.

Angiotensin II receptor antagonists, as well as ACE inhibitors, when used concomitantly with NSAIDs, enhance the reduction in glomerular filtration, which may thereby lead to the development of acute renal failure, especially in patients with impaired renal function.

Cholestyramine, by binding Meloxicam in the gastrointestinal tract, leads to its more rapid elimination.

Pemetrexed – with the simultaneous use of meloxicam and pemetrexed in patients with a creatinine clearance (CrCl) from 45 to 79 ml/min, meloxicam should be discontinued 5 days before starting pemetrexed and can be resumed 2 days after the last dose of pemetrexed. If concomitant use of meloxicam and pemetrexed is necessary, patients should be closely monitored, especially for myelosuppression and the occurrence of gastrointestinal adverse reactions. In patients with CrCl <45 ml/min, the use of meloxicam concomitantly with pemetrexed is not recommended.

NSAIDs, by affecting renal prostaglandins, may increase the nephrotoxicity of cyclosporine.

When used concomitantly with meloxicam and drugs known to inhibit CYP2C9 and/or CYP3A4 (or metabolized by these enzymes), such as sulfonylurea derivatives or probenecid, the possibility of a pharmacokinetic interaction should be considered.

When used concomitantly with oral hypoglycemic agents (e.g., sulfonylurea derivatives, nateglinide), a CYP2C9-mediated interaction is possible, which may lead to increased plasma concentrations of both the hypoglycemic agents and meloxicam. Patients concomitantly taking Meloxicam with sulfonylurea drugs or nateglinide should have their blood glucose levels carefully monitored due to the possibility of hypoglycemia.

Storage Conditions

Store at 2°C (36°F) to 25°C (77°F). Keep in original packaging, protected from light. Keep out of reach of children.

Dispensing Status

Rx Only

Important Safety Information

This information is for educational purposes only and does not replace professional medical advice. Always consult your doctor before use. Dosage and side effects may vary. Use only as prescribed.