Meloxicam is a long-acting non-steroidal anti-inflammatory drug (NSAID) available by prescription only and used in therapy of chronic arthritis. Meloxicam has been linked to rare instances of acute, clinically apparent liver injury.
Meloxicam (mel ox' i kam) is an enolic acid that belongs to oxicam class of NSAIDs similar to piroxicam. Like other NSAIDs, meloxicam is a potent cyclo-oxygenase (Cox-1 and Cox-2) inhibitor which blocks the formation of prostaglandins that are important in pain and inflammatory pathways. Meloxicam has analgesic as well as anti-pyretic and anti-inflammatory activities. Meloxicam has a ten-fold selectivity in inhibiting Cox-2 over Cox-1 in vitro. The specificity for Cox-2 is believed to make meloxicam less likely to cause gastrointestinal mucosal injury compared to standard NSAIDs that inhibit both Cox enzymes, which would suggest that it should have fewer gastrointestinal side effects and less effects on platelet function than the non-selective Cox inhibitors (Cox-1 and Cox-2). However, in humans, meloxicam in full doses has a similar side effect profile as most non-selective NSAIDs, and its clinical advantage has yet to be proven. Meloxicam was approved in the United States in 2000 and currently more than 9 million prescriptions are filled yearly. Current indications are for chronic osteoarthritis, rheumatoid arthritis and juvenile rheumatoid arthritis. Meloxicam is available by prescription only in 7.5 and 15 mg tablets in generic forms and under the brand name Mobic. The recommended dose is 7.5 to 15 mg once daily. Like most NSAIDs, meloxicam is generally well tolerated but side effects can include gastrointestinal upset and pain, nausea, headache, dizziness, somnolence, itching, peripheral edema and hypersensitivity reactions.
Prospective studies show that up to 7% of patients taking meloxicam experience at least transient serum aminotransferase elevations. These may resolve even with drug continuation. Aminotransferase elevations >3 fold elevated occur in 1% of patients. Clinically apparent liver injury with jaundice from meloxicam is rare and only individual case reports have been published. The latency to onset in reported cases was short (1-5 weeks) and both cholestatic and hepatocellular patterns of enzyme elevations were described. Immunoallergic features are usually not prominent and autoantibodies are rare, although a single case report of autoimmune hepatitis apparently triggered by meloxicam therapy has been published. Recovery is typically rapid once meloxicam is stopped. Meloxicam is rarely mentioned as an etiologic agent in large case series on drug-induced liver injury and acute liver failure.
Mechanism of Injury
The mechanism of meloxicam hepatotoxicity is not known.
Outcome and Management
Severity ranges from asymptomatic elevations in serum aminotransferase levels, to symptomatic hepatitis with or without jaundice. Fatal and chronic cases have not been described. Although cross-sensitivity has not been shown, patients with clinically apparent meloxicam-induced liver injury should probably avoid other oxicam NSAIDs such as piroxicam.
REPRESENTATIVE TRADE NAMES
Meloxicam – Mobic®
Anti-Inflammatory Agents, Nonsteroidal
FDA product labeling at DailyMed, National Library of Medicine, NIH
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References Last Updated: 11 February 2014
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