Meloxicam, sold under the brand name Mobic among others, is a nonsteroidal anti-inflammatory drug (NSAID) used to treat pain and inflammation in rheumatic diseases and osteoarthritis. It is taken by mouth or given by injection into a vein. It is recommended that it be used for as short a period as possible and at a low dose. Common side effects include abdominal pain, dizziness, swelling, headache, and a rash. Serious side effects may include heart disease, stroke, kidney problems, and stomach ulcers. Use is not recommended in the third trimester of pregnancy. It blocks cyclooxygenase-2 (COX-2) more than it blocks cyclooxygenase-1 (COX-1). It is in the oxicam family of chemicals and is closely related to piroxicam. It is available as a generic medication. In 2023, it was the 27th most commonly prescribed medication in the United States, with more than 20 million prescriptions. An intravenous version of meloxicam (Anjeso) was approved for medical use in the United States in February 2020. Meloxicam is available in combination with bupivacaine as bupivacaine/meloxicam and in combination with rizatriptan as meloxicam/rizatriptan.
Medical uses Meloxicam is indicated for the treatment of osteoarthritis, rheumatoid arthritis, and juvenile rheumatoid arthritis.
Adverse effects
Meloxicam use can result in gastrointestinal toxicity and bleeding, headaches, rash, and very dark or black stool (a sign of intestinal bleeding). It has fewer gastrointestinal side effects than diclofenac, piroxicam, naproxen, and perhaps all other NSAIDs which are not COX-2 selective. In October 2020, the US Food and Drug Administration (FDA) required the prescribing information to be updated for all nonsteroidal anti-inflammatory medications to describe the risk of kidney problems in unborn babies that result in low amniotic fluid. They recommend avoiding NSAIDs in pregnant women at 20 weeks or later in pregnancy.
Cardiovascular Like other NSAIDs, its use is associated with an increased risk of cardiovascular events such as heart attack and stroke. Although meloxicam inhibits formation of thromboxane A, it does not appear to do so at levels that would interfere with platelet function. A pooled analysis of randomized, controlled studies of meloxicam therapy of up to 60 days duration found that meloxicam was associated with a statistically significantly lower number of thromboembolic complications than the NSAID diclofenac (0.2% versus 0.8% respectively) but a similar incidence of thromboembolic events to naproxen and piroxicam. People with hypertension, high cholesterol, or diabetes are at risk for cardiovascular side effects. People with family history of heart disease, heart attack, or stroke should tell their treating physician as the potential for serious cardiovascular side effects is significant.
Gastrointestinal NSAIDs cause an increase in the risk of serious gastrointestinal adverse events including bleeding, ulceration, and perforation of the stomach or intestines, which can be fatal. Elderly patients are at greater risk for serious gastrointestinal events.
Mechanism of action
Meloxicam blocks cyclooxygenase (COX), the enzyme responsible for converting arachidonic acid into prostaglandin H2—the first step in the synthesis of prostaglandins, which are mediators of inflammation. Meloxicam has been shown, especially at low therapeutic doses, to selectively inhibit COX-2 over COX-1. X-ray crystallographic analyses and molecular modelling studies of meloxicam´s binding to cyclooxygenase isoforms showed that the methyl group of the thiazole ring in meloxicam exploits the "flexible extra space" at the top of the COX-2 channel. The substitution of the second shell amino acid residue Ile434 in COX-1 by Val in COX-2 allows the side chain of Phe518 (a residue at the active side) to open "extra space", which favors the binding of meloxicam to COX-2. Site-directed mutagenesis studies in which Ile434 was substituted for Val434 in COX-2 confirmed this hypothesis. Other oxicams also occupy this binding site, albeit nonselectively because of the missing methyl group in the side chain. Meloxicam concentrations in synovial fluid range from 40% to 50% of those in plasma. The free fraction in synovial fluid is 2.5 times higher than in plasma, due to the lower albumin content in synovial fluid compared to plasma. The significance of this penetration is unknown, but it may account for the fact that it performs exceptionally well in treatment of arthritis in animal models.
Pharmacokinetics
Absorption The bioavailability of meloxicam is decreased when administered orally compared to an equivalent IV bolus dose. Different oral formulations of meloxicam are not bioequivalent. Use of oral meloxicam following a high-fat breakfast increases the mean peak drug levels by about 22%; however, the manufacturer does not make any specific meal recommendations. In addition, the use of antacids does not show pharmacokinetic interactions. With chronic dosing, the time to maximum plasma concentration following oral administration is approximately 5–6 hours.
Distribution The mean volume of distribution of meloxicam is approximately 10 L. It is highly protein-bound, mainly to albumin.
Metabolism Meloxicam is extensively metabolized in the liver by the enzymes CYP2C9 and CYP3A4 (minor) into four inactive metabolites. Peroxidase activity is thought to be responsible for the other two remaining metabolites.
Excretion Meloxicam is predominantly excreted in the form of metabolites and occurs to equal extents in the urine and feces. Traces of unchanged parent drug are found in urine and feces. The mean elimination half-life ranges from 15 to 20 hours. Adverse events are dose-dependent and associated with length of treatment.
Research and development In the 1970s, chemists at Dr. Karl Thomae GmbH, a subsidiary of Boehringer-Ingelheim in Germany, synthesized a variety of enol carboxamides with the aim of obtaining active ingredients with anti-inflammatory or antithrombotic properties. A compound belonging to the oxicams (UH-AC 62, meloxicam) stood out, exhibiting antiinflammatory activity in the pharmacological adjuvant arthritis model, but only low antithrombotic efficacy as measured by platelet aggregation. Dr. Karl Thomae GmbH filed the German basic patent DE2756113 (1979) and Boehringer Ingelheim US patent 4,233,299 (1980) and patents in many other countries.
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