Meloxicam Stella Drug Interactions

Interaction studies have only been performed in adults.
Meloxicam is metabolised in liver, mostly by CYP2C9 and CYP3A4. Possibility of pharmacokinetic interactions between meloxicam and drugs inhibiting or being metabolised by CYP2C9 and CYP3A4 has to be considered.
Pharmacodynamic interactions: Other non-steroidal anti-inflammatory drugs (NSAIDs) and acetylsalicylic acid ≥3 g/d: Combination with other non-steroidal anti-inflammatory drugs, including acetylsalicylic acid given at anti-inflammatory doses (≥1 g as single intake or ≥3 g as total daily amount), is not recommended.
Corticosteroids (e.g. Glucocorticoids): The concomitant use with corticosteroids requests caution because of an increased risk of bleeding or gastrointestinal ulceration.
Anticoagulant or heparin administered in geriatrics or at curative doses: Considerably increased risk of bleeding, via inhibition of platelet function and damage to the gastroduodenal mucosa. NSAIDs may enhance the effects of anticoagulants, such as warfarin. The concomitant use of NSAIDs and anticoagulants or heparin administered in geriatrics or at curative dose is not recommended.
In remaining cases of heparin use, caution is necessary due to an increased bleeding risk. Careful monitoring of the INR is required if it proves impossible to avoid such combination.
Thrombolytics and antiplatelet drugs: Increased risk of bleeding, via inhibition of platelet function and damage to the gastroduodenal mucosa.
Selective serotonin reuptake inhibitors (SSRIs): Increased risk of gastrointestinal bleeding.
Diuretics, ACE inhibitors and Angiotensin-II antagonists: NSAIDs may reduce the effect of diuretics and other antihypertensive drugs. In some patients with compromised renal function (e.g. dehydrated patients or elderly patients with compromised renal function), the co-administration of an ACE inhibitor or angiotensin-II antagonists and agents that inhibit cyclooxygenase may result in further deterioration of renal function, including possible acute renal failure, which is usually reversible. Therefore, the combination should be administered with caution, especially in the elderly. Patients should be adequately hydrated and consideration should be given to monitoring of renal function after initiation of concomitant therapy, and periodically thereafter.
Other antihypertensive drugs (e.g. Beta-blockers): As for the latter, a decrease of the antihypertensive effect of beta-blockers (due to inhibition of prostaglandins with vasodilatory effect) can occur.
Calcineurin inhibitors (e.g. cyclosporine, tacrolimus): Nephrotoxicity of calcineurin inhibitors may be enhanced by NSAIDs via renal prostaglandin-mediated effects. During combined treatment, renal function is to be measured. A careful monitoring of the renal function is recommended, especially in the elderly.
Intrauterine devices: NSAIDs have been reported to decrease the efficacy of intrauterine devices.
A decrease of the efficacy of intrauterine devices by NSAIDs has been previously reported but needs further confirmation.
Pharmacokinetic interactions: Effect of meloxicam on the pharmacokinetics of other drugs: Lithium: NSAIDs have been reported to increase blood lithium levels (via decreased renal excretion of lithium), which may reach toxic values. The concomitant use of lithium and NSAIDs is not recommended. If this combination appears necessary, lithium plasma concentrations should be monitored carefully during the initiation, adjustment and withdrawal of meloxicam treatment.
Methotrexate: NSAIDs can reduce the tubular secretion of methotrexate, thereby increasing the plasma concentrations of methotrexate. For this reason, for patients on high dosages of methotrexate (more than 15 mg/week), the concomitant use of NSAIDs is not recommended.
The risk of an interaction between NSAID preparations and methotrexate should be considered also in patients on low dosage of methotrexate, especially in patients with impaired renal function. In case combination treatment is necessary, blood cell count and the renal function should be monitored. Caution should be taken in case both NSAID and methotrexate are given within 3 days, in which case the plasma level of methotrexate may increase and cause increased toxicity.
Although the pharmacokinetics of methotrexate (15 mg/week) were not relevantly affected by concomitant meloxicam treatment, it should be considered that the haematological toxicity of methotrexate can be amplified by treatment with NSAID drugs.
Effect of other drugs on the pharmacokinetics of meloxicam: No clinically relevant pharmacokinetic drug-drug interactions were detected with respect to the concomitant administration of antacids, cimetidine and digoxin.
Cholestyramine: Cholestyramine accelerates the elimination of meloxicam by interrupting the enterohepatic circulation so that clearance for meloxicam increases by 50% and the half-life decreases to 13+3 hrs. This interaction is of clinical significance.