for medical use of the medicinal product MELOX (MELOX)

Composition:

Active substance: meloxicam;

1 tablet contains 15 mg of meloxicam;

Excipients: sodium citrate*; lactose monohydrate; microcrystalline cellulose; povidone; crospovidone; colloidal anhydrous silicon dioxide; magnesium stearate.

* Dihydrate.

Pharmaceutical form. Tablets.

Main physicochemical characteristics: light yellow, round, flat tablets with a score line on one side. Diameter approximately 10.5 mm. Thickness: 2.85–3.35 mm.

Pharmacotherapeutic group. Non-steroidal anti-inflammatory and antirheumatic agents. Oxicams. ATC code M01AC06.

Pharmacological Properties.

Pharmacodynamics.

Melox is a non-steroidal anti-inflammatory drug (NSAID) of the oxicam class, possessing anti-inflammatory, analgesic, and antipyretic effects. Meloxicam has demonstrated high anti-inflammatory activity in standard models of inflammation. As with other NSAIDs, its exact mechanism of action remains unknown. However, there is a common mechanism of action shared by all NSAIDs (including meloxicam): inhibition of prostaglandin biosynthesis, which are mediators of inflammation.

Pharmacokinetics.

Absorption. Meloxicam is well absorbed from the gastrointestinal tract following oral administration (capsules), with an absolute bioavailability of 90%. Tablets, oral suspension, and capsules have demonstrated bioequivalence. After single administration, maximum plasma concentration is reached within 5–6 hours for solid oral dosage forms (capsules and tablets). At steady-state, achieved by the 3rd to 5th day with repeated dosing, once-daily dosing results in average plasma concentrations with relatively small peak fluctuations: ranging from 0.4–1.0 µg/mL for the 7.5 mg dose and 0.8–2.0 µg/mL for the 15 mg dose (Cmin and Cmax at steady state, respectively). The average peak plasma concentrations of meloxicam at steady state are reached within 5–6 hours following administration in tablet, capsule, or oral suspension formulations. During continuous treatment periods exceeding one year, plasma concentrations remain comparable to those observed at steady state at the beginning of therapy. Oral absorption of meloxicam is not altered by concomitant food intake or by co-administration with mineral antacids.

Distribution. Meloxicam is highly bound to plasma proteins, primarily albumin (99%). Meloxicam penetrates into synovial fluid, where its concentration is approximately half that in plasma. The volume of distribution is low, averaging 11 L after intramuscular or intravenous administration, with individual variations ranging from 7% to 20%. The volume of distribution after multiple oral doses of meloxicam (7.5 to 15 mg) is 16 L, with a coefficient of variation ranging from 11% to 32%.

Biological transformation. Meloxicam undergoes extensive biotransformation in the liver. Four different metabolites of meloxicam, pharmacodynamically inactive, have been identified in urine. The main metabolite, 5’-carboxymeloxicam (60% of dose), is formed via oxidation of the intermediate metabolite 5’-hydroxymethylmeloxicam, which is excreted to a lesser extent (9% of dose). In vitro studies suggest that CYP2C9 plays a major role in the metabolic process, while CYP3A4 contributes to a lesser extent. Peroxidase activity in patients may be responsible for two other metabolites, accounting for 16% and 4% of the administered dose, respectively.

Elimination. Meloxicam is excreted primarily as metabolites in equal proportions in urine and feces. Less than 5% of the daily dose is excreted unchanged in feces, and a negligible amount is excreted in urine. The elimination half-life ranges from 13 to 25 hours following oral, intramuscular, or intravenous administration. Plasma clearance is approximately 7–12 mL/min after a single oral dose, intravenous, or rectal administration.

Dose linearity. Meloxicam exhibits linear pharmacokinetics within the therapeutic dose range of 7.5 mg to 15 mg following oral and intramuscular administration.

Special patient groups.

Patients with hepatic/renal impairment. Mild to moderate hepatic and renal impairment do not significantly affect the pharmacokinetics of meloxicam. Patients with moderate renal impairment showed significantly higher total clearance. Reduced plasma protein binding was observed in patients with end-stage renal disease. In end-stage renal disease, increased volume of distribution may lead to elevated concentrations of free meloxicam (see section "Dosage and administration" and "Contraindications").

Elderly patients. In elderly male patients, average pharmacokinetic parameters are similar to those in young male volunteers. In elderly female patients, AUC values are higher and elimination half-life is longer compared to young volunteers of both sexes. Average plasma clearance at steady state in elderly patients was slightly lower than in young volunteers (see section "Dosage and administration").

Clinical characteristics.

Indications.

Short-term symptomatic treatment of osteoarthritis exacerbation.

Long-term symptomatic treatment of rheumatoid arthritis and ankylosing spondylitis.

Melox, tablets, is indicated for the treatment of adults and children aged 16 years and older.

Contraindications.

Hypersensitivity to the active substance or to any of the excipients;
hypersensitivity to active substances with similar effects, such as nonsteroidal anti-inflammatory drugs (NSAIDs), aspirin. Meloxicam should not be administered to patients who have experienced asthma symptoms, nasal polyps, angioedema, or urticaria after taking aspirin or other NSAIDs;
third trimester of pregnancy (see section "Use during pregnancy or breastfeeding");
children under 16 years of age;
gastrointestinal bleeding or perforation related to previous NSAID therapy in medical history;
active or recurrent peptic ulcer/hemorrhage in medical history (two or more separate confirmed episodes of ulcer or bleeding);
severe hepatic impairment;
severe renal impairment without dialysis;
gastrointestinal bleeding, cerebrovascular hemorrhage in medical history, or other coagulation disorders;
severe heart failure;
treatment of perioperative pain in coronary artery bypass grafting (CABG).

Interaction with other medicinal products and other forms of interactions.

Risks associated with hyperkalemia. Some medicinal products or therapeutic groups may promote hyperkalemia: potassium salts, potassium-sparing diuretics, angiotensin-converting enzyme inhibitors (ACE inhibitors), angiotensin II receptor antagonists, nonsteroidal anti-inflammatory drugs, (low molecular weight or unfractionated) heparins, cyclosporine, tacrolimus, and trimethoprim. The onset of hyperkalemia may depend on whether associated factors are present. The risk of hyperkalemia increases if the aforementioned medicinal products are used concomitantly with meloxicam.

Pharmacodynamic interactions.

Other nonsteroidal anti-inflammatory drugs (NSAIDs) and acetylsalicylic acid. Combination with other NSAIDs is not recommended (see section "Special precautions for use"), including acetylsalicylic acid at doses ≥ 500 mg per dose or ≥ 3 g total daily dose.

Corticosteroids (e.g., glucocorticoids). Concurrent use with corticosteroids requires caution due to an increased risk of gastrointestinal bleeding or ulceration.

Anticoagulants or heparin. The risk of bleeding is significantly increased due to platelet function inhibition and gastroduodenal mucosal damage. NSAIDs may enhance the effects of anticoagulants such as warfarin (see section "Special precautions for use"). Concomitant use of NSAIDs and anticoagulants or heparin is not recommended in geriatric practice or at therapeutic doses (see section "Special precautions for use"). In other cases (e.g., for prophylactic doses), heparin use requires caution due to an increased risk of bleeding. Careful monitoring of INR (international normalized ratio) is necessary if such a combination cannot be avoided.

Thrombolytic and antiplatelet agents. Increased risk of bleeding due to platelet function inhibition and gastroduodenal mucosal damage.

Selective serotonin reuptake inhibitors (SSRIs). Increased risk of gastrointestinal bleeding.

Diuretics, ACE inhibitors, and angiotensin II antagonists. NSAIDs may reduce the efficacy of diuretics and other antihypertensive medicinal products. In some patients with impaired renal function (e.g., dehydrated patients or elderly patients with renal impairment), concomitant use of ACE inhibitors or angiotensin II antagonists and medicinal products that inhibit cyclooxygenase may lead to further deterioration of renal function, including possible acute renal failure, which is usually reversible. Therefore, combination therapy should be used with caution, especially in elderly patients. Patients should receive adequate hydration, and renal function should be monitored after initiation of combination therapy and periodically thereafter (see section "Special precautions for use").

Other antihypertensive medicinal products (e.g., beta-blockers). As with the medicinal products mentioned below, a possible reduction in the antihypertensive effect of beta-blockers may occur (due to inhibition of vasodilatory prostaglandins).

Calcineurin inhibitors (e.g., cyclosporine, tacrolimus). The nephrotoxicity of calcineurin inhibitors may be potentiated by NSAIDs due to mediation of renal prostaglandin effects. Renal function should be monitored during treatment. Careful monitoring of renal function is recommended, especially in elderly patients.

Deferasirox. Concomitant use of meloxicam and deferasirox may increase the risk of gastrointestinal adverse reactions. Caution should be exercised when combining these medicinal products.

Pharmacokinetic interaction: effect of meloxicam on the pharmacokinetics of other medicinal products.

Lithium. Data on NSAIDs indicate increased plasma lithium concentrations (due to reduced renal excretion of lithium), which may reach toxic levels. Concomitant use of lithium and NSAIDs is not recommended. If combination therapy is necessary, plasma lithium levels should be closely monitored at the start of treatment, during dose adjustment, and upon discontinuation of meloxicam.

Metotrexate. NSAIDs may reduce tubular secretion of methotrexate, thereby increasing its plasma concentration. For this reason, concomitant use of NSAIDs is not recommended in patients receiving high-dose methotrexate (over 15 mg/week) (see section "Special precautions for use"). The risk of interaction between NSAIDs and methotrexate should also be considered in patients receiving low-dose methotrexate, particularly those with impaired renal function. If combination therapy is required, blood test parameters and renal function should be monitored. Caution is advised if NSAID and methotrexate administration continues for 3 consecutive days, as plasma methotrexate levels may increase and enhance toxicity. Although the pharmacokinetics of methotrexate (15 mg/week) were not affected by concomitant meloxicam treatment, hematological toxicity of methotrexate may increase with NSAID treatment (see information provided above) (see section "Adverse reactions").

Pemetrexed. When meloxicam is used concomitantly with pemetrexed in patients with creatinine clearance between 45 and 79 mL/min, meloxicam administration should be suspended 5 days before, on the day of, and 2 days after pemetrexed infusion. If the combination of meloxicam with pemetrexed is necessary, patients should be closely monitored, particularly for myelosuppression and gastrointestinal adverse reactions. Concomitant use of meloxicam with pemetrexed is not recommended in patients with severe renal impairment (creatinine clearance below 45 mL/min). In patients with normal renal function (creatinine clearance ≥ 80 mL/min), a 15 mg dose of meloxicam may reduce pemetrexed elimination and thus increase the frequency of pemetrexed-related adverse reactions. Therefore, caution should be exercised when prescribing 15 mg meloxicam concurrently with pemetrexed in patients with normal renal function (creatinine clearance ≥ 80 mL/min).

Pharmacokinetic interaction: effect of other medicinal products on the pharmacokinetics of meloxicam.

Cholestyramine. Cholestyramine accelerates meloxicam elimination due to disruption of enterohepatic circulation, resulting in a 50% increase in meloxicam clearance and a reduction in half-life to 13±3 hours. This interaction is clinically significant.

Pharmacokinetic interaction: effect of the combination of meloxicam and other medicinal products on pharmacokinetics.

Oral antidiabetic agents (sulfonylurea derivatives, nateglinide). Meloxicam is almost entirely eliminated via hepatic metabolism, approximately two-thirds mediated by cytochrome P450 enzymes (mainly CYP 2C9 and partially CYP 3A4) and one-third via other pathways, such as peroxidative oxidation. Potential pharmacokinetic interactions should be considered when meloxicam is administered concomitantly with medicinal products that strongly inhibit or are metabolized by CYP 2C9 and/or CYP 3A4. Interactions mediated by CYP 2C9 may be expected when combined with medicinal products such as oral antidiabetic agents (sulfonylurea derivatives, nateglinide); this interaction may lead to increased plasma levels of these agents and meloxicam. Patients receiving meloxicam and sulfonylurea or nateglinide should be closely monitored for the development of hypoglycemia.

No clinically significant pharmacokinetic interaction was observed with concomitant administration of antacids, cimetidine, or digoxin.

Children. Interaction studies have been conducted only in adults.

Special precautions for use.

Adverse reactions can be minimized by using the lowest effective dose for the shortest duration necessary to control symptoms (see section "Dosage and administration" and information on gastrointestinal and cardiovascular risks below). The recommended maximum daily dose should not be exceeded if there is insufficient therapeutic effect, and additional NSAIDs should not be used, as this may increase toxicity without proven therapeutic benefits. Concomitant use of meloxicam with NSAIDs, including selective cyclooxygenase-2 inhibitors, should be avoided. Meloxicam is not suitable for the treatment of patients requiring relief from acute pain. If no improvement is observed after several days, the clinical benefit of treatment should be re-evaluated. Attention should be paid to a history of esophagitis, gastritis, and/or peptic ulcer to ensure their complete treatment before starting meloxicam therapy. Patients treated with meloxicam and those with such history should be regularly monitored for possible recurrence.

Gastrointestinal disorders. As with other NSAIDs, potentially fatal gastrointestinal bleeding, ulceration, or perforation may occur at any time during treatment, with or without prior symptoms or serious gastrointestinal disease history. The risk of gastrointestinal bleeding, ulceration, or perforation increases with higher NSAID doses in patients with a history of ulcers, especially complicated by bleeding or perforation (see section "Contraindications"), and in elderly patients. Such patients should start treatment with the lowest effective dose. For these patients, combination therapy with protective agents (such as misoprostol or proton pump inhibitors) should be considered, as well as for patients requiring concomitant use of low-dose aspirin or other agents increasing gastrointestinal risks (see information below and section "Interaction with other medicinal products and other forms of interaction"). Patients with a history of gastrointestinal toxicity, especially elderly patients, should be informed about all unusual abdominal symptoms (particularly gastrointestinal bleeding), especially in the early stages of treatment. Meloxicam is not recommended for patients who are concomitantly using medicinal products that may increase the risk of ulceration or bleeding, such as heparin, as radical therapy or in geriatric practice, anticoagulants such as warfarin, or other non-steroidal anti-inflammatory drugs, including acetylsalicylic acid at doses ≥ 500 mg per dose or ≥ 3 g total daily dose (see section "Interaction with other medicinal products and other forms of interaction"). If gastrointestinal bleeding or ulceration occurs in patients taking meloxicam, treatment should be discontinued. NSAIDs should be used with caution in patients with a history of gastrointestinal disorders (ulcerative colitis, Crohn's disease), as these conditions may worsen (see section "Adverse reactions").

Hepatic disorders. Up to 15% of patients taking NSAIDs (including meloxicam) may experience elevated levels of one or more liver function tests. These laboratory abnormalities may progress, remain unchanged, or be transient during continued treatment. Marked elevations of ALT or AST (approximately three times or more above normal) were observed in 1% of patients during clinical trials with NSAIDs. Additionally, rare cases of severe hepatic reactions, including jaundice and fulminant fatal hepatitis, liver necrosis, and liver failure, some with fatal outcomes, have been reported. Patients with symptoms or suspected hepatic dysfunction or those with abnormal liver function tests should be evaluated for signs of more severe hepatic failure during meloxicam therapy. If clinical signs and symptoms suggest hepatic disease or if systemic manifestations of disease (e.g., eosinophilia, rash, etc.) are observed, the drug should be discontinued.

Cardiovascular disorders. Careful monitoring is recommended for patients with a history of arterial hypertension and/or mild to moderate congestive heart failure, as fluid retention and edema have been observed during NSAID therapy. Clinical monitoring of blood pressure is recommended at the beginning of therapy, especially at the start of meloxicam treatment, for patients with risk factors. Data from studies and epidemiological data suggest that the use of some NSAIDs (particularly at high doses and with prolonged treatment) may be associated with a small increased risk of vascular thrombotic events (e.g., myocardial infarction or stroke). There is insufficient data to exclude such a risk for meloxicam. Meloxicam therapy should be initiated only after careful consideration in patients with uncontrolled arterial hypertension, congestive heart failure, established ischemic heart disease, peripheral arterial disease, and/or cerebrovascular disease. A similar assessment is necessary before initiating long-term treatment in patients with cardiovascular risk factors (such as arterial hypertension, hyperlipidemia, diabetes mellitus, smoking). NSAIDs may increase the risk of serious cardiovascular thrombotic events, myocardial infarction, and stroke, which may be fatal. The risk increases with the duration of use. Patients with cardiovascular diseases or cardiovascular risk factors may have an increased risk.

Skin reactions. Life-threatening severe skin reactions, including Stevens-Johnson syndrome and toxic epidermal necrolysis, have been reported with meloxicam use. Patients should be informed about the signs and symptoms of severe skin reactions and closely monitored for skin reactions. The highest risk of Stevens-Johnson syndrome or toxic epidermal necrolysis occurs during the first weeks of treatment. If a patient presents symptoms or signs of Stevens-Johnson syndrome or toxic epidermal necrolysis (e.g., progressive skin rash often with blisters or mucosal involvement), meloxicam treatment should be discontinued. It is crucial to diagnose promptly and discontinue any drugs that may cause severe skin reactions: Stevens-Johnson syndrome or toxic epidermal necrolysis. This is associated with a better prognosis in severe skin reactions. If a patient develops Stevens-Johnson syndrome or toxic epidermal necrolysis while using meloxicam, the drug must not be restarted at any time in the future. Cases of fixed drug eruption have been reported with meloxicam use. Meloxicam should not be re-administered to patients with a history of fixed drug eruption associated with meloxicam use. Potential cross-reactivity may occur with other oxicams.

Anaphylactoid reactions. As with other NSAIDs, anaphylactoid reactions may occur in patients without known hypersensitivity to meloxicam. Meloxicam should not be used in patients with aspirin triad. This symptomatic complex occurs in patients with asthma who have reported rhinitis with or without nasal polyps or who have experienced severe, potentially fatal bronchospasm after taking aspirin or other NSAIDs. Emergency measures should be taken if an anaphylactoid reaction is detected.

Liver parameters and renal function. As with treatment with most NSAIDs, isolated cases of elevated serum transaminase levels, elevated serum bilirubin levels, or other liver function parameters, as well as elevated serum creatinine and blood urea nitrogen, and other laboratory abnormalities have been described. In most cases, these abnormalities were minor and transient. Meloxicam use should be discontinued and follow-up tests performed if significant or persistent abnormalities are confirmed.

Functional renal failure. NSAIDs, by inhibiting the vasodilatory effect of renal prostaglandins, may induce functional renal failure due to decreased glomerular filtration. This adverse effect is dose-dependent. Careful monitoring of diuresis and renal function is recommended at the beginning of treatment or after dose increase in patients with the following risk factors:

advanced age;
concomitant use with ACE inhibitors, angiotensin II antagonists, sartans, diuretics (see section "Interaction with other medicinal products and other forms of interaction");
hypovolemia (of any origin);
congestive heart failure;
renal failure;
nephrotic syndrome;
lupus nephropathy;
severe hepatic dysfunction (serum albumin < 25 g/L or ≥ 10 according to Child-Pugh classification).

In isolated cases, NSAIDs may lead to interstitial nephritis, glomerulonephritis, renal medullary necrosis, or nephrotic syndromes. The dose of meloxicam for patients with end-stage renal failure on dialysis should not exceed 7.5 mg. The dose need not be reduced in patients with mild to moderate renal impairment (creatinine clearance > 25 mL/min).

Sodium, potassium, and water retention. NSAIDs may enhance sodium, potassium, and water retention and affect the natriuretic effects of diuretics. Additionally, a reduction in the antihypertensive effect of antihypertensive drugs may occur (see section "Interaction with other medicinal products and other forms of interaction"). As a result, edema, heart failure, or arterial hypertension may be accelerated or exacerbated in susceptible patients. Therefore, clinical monitoring is recommended for patients with such risks (see sections "Dosage and administration" and "Contraindications").

Hyperkalemia. Hyperkalemia may be promoted by diabetes mellitus or concomitant use of drugs that increase potassium levels (see section "Interaction with other medicinal products and other forms of interaction"). Regular monitoring of potassium levels is required in such cases.

Combination with pemetrexed. In patients with mild to moderate renal impairment receiving pemetrexed, meloxicam treatment should be suspended at least 5 days before pemetrexed administration, on the day of administration, and for at least 2 days after administration (see section "Interaction with other medicinal products and other forms of interaction").

Other warnings and safety measures. Adverse reactions are often less well tolerated in elderly, debilitated, or weakened patients, who require careful monitoring. As with treatment with other NSAIDs, caution is required in elderly patients, in whom reduced renal, hepatic, and cardiac function is more likely. Elderly patients have a higher frequency of adverse reactions to NSAIDs, particularly gastrointestinal bleeding and perforations, which may be fatal (see section "Dosage and administration"). Meloxicam, like any other NSAID, may mask symptoms of infectious diseases. The use of meloxicam may negatively affect reproductive function and is not recommended for women wishing to become pregnant. Therefore, for women planning pregnancy or undergoing infertility evaluation, discontinuation of meloxicam should be considered (see section "Use during pregnancy or breastfeeding").

The 15 mg Melox tablets contain lactose; therefore, this medication is not recommended for patients with rare hereditary galactose intolerance, total lactase deficiency, or glucose-galactose malabsorption.

Masking of inflammation and fever. The pharmacological action of Melox in reducing fever and inflammation may complicate diagnosis in suspected non-infectious painful conditions.

Treatment with corticosteroids. Meloxicam cannot be a substitute for corticosteroids in the treatment of corticosteroid deficiency.

Hematological effects. Anemia may occur in patients receiving NSAIDs, including meloxicam. This may be related to fluid retention, gastrointestinal bleeding of unknown origin, either microscopic or macroscopic, or incompletely described effects on erythropoiesis. Patients undergoing long-term treatment with NSAIDs, including meloxicam, should have hemoglobin or hematocrit monitored if symptoms and signs of anemia are present. NSAIDs inhibit platelet aggregation and may prolong bleeding time in some patients. Unlike aspirin, their effect on platelet function is quantitatively less, transient, and reversible. The condition of patients taking meloxicam who may have adverse effects related to changes in platelet function, particularly coagulation disorders, or patients receiving anticoagulants, should be carefully monitored.

Use in patients with asthma. Patients with asthma may have aspirin-sensitive asthma. The use of aspirin in patients with aspirin-sensitive asthma is associated with severe bronchospasm, which may be fatal. Due to cross-reactivity, including bronchospasm, between aspirin and other NSAIDs, meloxicam should not be used in patients sensitive to aspirin and should be used cautiously in patients with asthma.

Use during pregnancy or breastfeeding.

Pregnancy. Inhibition of prostaglandin synthesis may adversely affect pregnancy and/or embryonic and fetal development. Epidemiological data suggest an increased risk of miscarriage and congenital heart defects and gastroschisis after use of prostaglandin synthesis inhibitors in early pregnancy. The absolute risk of congenital heart defects increased from less than 1% to about 1.5%. This risk is believed to increase with increasing dose and duration of treatment. In animal studies, administration of a prostaglandin synthesis inhibitor led to increased pre- and post-implantation losses and embryofetal mortality. Furthermore, in animals receiving a prostaglandin synthesis inhibitor during organogenesis, an increased frequency of various developmental abnormalities, including cardiovascular, has been reported. Starting from the 20th week of pregnancy, the use of meloxicam may cause oligohydramnios due to fetal renal dysfunction. This may occur soon after the start of treatment and is usually reversible after discontinuation of the drug. Additionally, cases of arterial duct constriction after treatment in the second trimester have been reported, most of which resolved after discontinuation of treatment. Therefore, meloxicam should not be used during the first and second trimesters of pregnancy, except in cases of urgent need. If a woman is trying to become pregnant or is using meloxicam during the first and second trimesters of pregnancy, the dosage and duration of treatment should be as low as possible. Prenatal monitoring for oligohydramnios and arterial duct constriction after meloxicam exposure should be considered for several days starting from the 20th week of pregnancy. If oligohydramnios or arterial duct constriction is detected, meloxicam use should be discontinued.

During the third trimester of pregnancy, all prostaglandin synthesis inhibitors may pose risks to the fetus:

cardiopulmonary toxicity (with premature constriction/closure of the arterial duct and pulmonary hypertension);
renal dysfunction (see above);

possible risks in late pregnancy for the woman and newborn:

potential for prolonged bleeding time, anti-aggregatory effect even at very low doses;
inhibition of uterine contractions leading to delayed or prolonged labor.

Therefore, meloxicam is contraindicated during the third trimester of pregnancy.

Breastfeeding. Although specific data on Melox are lacking, it is known that NSAIDs can pass into breast milk. Therefore, use is not recommended for women who are breastfeeding.

Fertility. Meloxicam, like other medicinal products that inhibit cyclooxygenase/prostaglandin synthesis, may negatively affect reproductive function and is not recommended for women wishing to become pregnant. Therefore, for women planning pregnancy or undergoing infertility evaluation, discontinuation of meloxicam should be considered.

Ability to affect reaction speed when driving vehicles or operating machinery.

No specific studies have been conducted on the effect of the drug on the ability to drive vehicles or operate machinery. However, based on the pharmacodynamic profile and observed adverse reactions, it can be assumed that meloxicam is likely to have no effect or a negligible effect on such activities. Nevertheless, patients who experience visual disturbances, including blurred vision, dizziness, somnolence, vertigo, or other central nervous system disorders, are advised to refrain from driving vehicles or operating machinery.

Dosage and Administration

Dosage. The total daily dose of the medicinal product should be taken once daily. Adverse reactions can be minimized by using the lowest effective dose for the shortest duration necessary to control symptoms (see section "Special Warnings and Precautions for Use"). The patient's need for symptomatic relief and response to therapy should be periodically reassessed, particularly in patients with osteoarthritis.

Osteoarthritis flare-up: 7.5 mg once daily (half of a 15 mg tablet). If necessary, the dose may be increased to 15 mg once daily (one 15 mg tablet).

Rheumatoid arthritis, ankylosing spondylitis: 15 mg once daily (one 15 mg tablet).

See also section "Special Patient Populations" below.

The dose may be reduced to 7.5 mg once daily (half of a 15 mg tablet) based on therapeutic response.

DO NOT EXCEED THE DOSE OF 15 mg ONCE DAILY.

Special Patient Populations

Elderly patients (see section "Pharmacokinetics"). The recommended dose for long-term treatment of rheumatoid arthritis and ankylosing spondylitis in elderly patients is 7.5 mg once daily (also see section "Dosage and Administration" – "Patients at increased risk of adverse reactions" and section "Special Warnings and Precautions for Use").

Patients at increased risk of adverse reactions (see section "Special Warnings and Precautions for Use"). For patients at increased risk of adverse reactions, e.g., those with a history of gastrointestinal disorders or risk factors for cardiovascular disease, treatment should be initiated at a dose of 7.5 mg once daily.

Renal impairment (see section "Pharmacokinetics"). This medicinal product is contraindicated in patients with severe renal impairment not undergoing hemodialysis (see section "Contraindications"). For patients with end-stage renal disease undergoing hemodialysis, the daily dose should not exceed 7.5 mg. Dose adjustment is not required in patients with mild to moderate renal impairment (i.e., patients with creatinine clearance above 25 mL/min).

Hepatic impairment (see section "Pharmacokinetics"). Dose adjustment is not required in patients with mild to moderate hepatic impairment (for patients with severe hepatic impairment, see section "Contraindications").

Administration. For oral use. Melox should be taken with water or another liquid, during meals.

Pediatric population

Melox 15 mg tablets are contraindicated in children under 16 years of age (see section "Contraindications").

Overdose

Symptoms. Symptoms of acute NSAID overdose are usually limited to lethargy, drowsiness, nausea, vomiting, and epigastric pain, which are generally reversible with supportive care. Gastrointestinal bleeding may occur. Severe poisoning may lead to arterial hypertension, acute renal failure, hepatic dysfunction, respiratory depression, coma, convulsions, cardiovascular failure, and cardiac arrest. Anaphylactoid reactions have been reported during therapeutic use of NSAIDs and may also occur in overdose.

Treatment. In case of NSAID overdose, symptomatic and supportive measures are recommended. Studies have shown that oral administration of cholestyramine 4 g three times daily accelerates the elimination of meloxicam.

Side effects.

General description. Data from studies and epidemiological evidence suggest that the use of certain NSAIDs (especially at high doses and with long-term treatment) may be associated with a small increased risk of thrombotic events (e.g., myocardial infarction or stroke) (see section "Special precautions"). Edema, arterial hypertension, and heart failure have been observed during NSAID therapy. Most of the adverse effects observed are gastrointestinal in origin. Peptic ulceration, perforation, or gastrointestinal bleeding, sometimes fatal, may occur, particularly in elderly patients (see section "Special precautions"). After administration, nausea, vomiting, diarrhea, flatulence, constipation, dyspepsia, abdominal pain, melena, hematemesis, ulcerative stomatitis, and exacerbations of colitis and Crohn's disease have been observed (see section "Special precautions"). Gastritis has been observed less frequently. Serious skin reactions have been reported: Stevens-Johnson syndrome and toxic epidermal necrolysis (see section "Special precautions"). The frequency of the adverse reactions listed below is based on reported adverse events recorded in 27 clinical trials with treatment duration of at least 14 days. The information is based on clinical trials involving 15,197 patients who received oral meloxicam at daily doses of 7.5 or 15 mg in tablet or capsule form for up to one year. Also included are adverse reactions identified from post-marketing surveillance reports.

Criteria for assessing the frequency of adverse reactions: very common (≥ 1/10); common (≥ 1/100 to < 1/10); uncommon (≥ 1/1,000 to < 1/100); rare (≥ 1/10,000 to < 1/1,000); very rare (< 1/10,000); not known (cannot be estimated from available data).

Blood and lymphatic system disorders: uncommon – anemia; rare – blood test abnormalities (including changes in leukocyte count), leukopenia, thrombocytopenia. Very rare cases of agranulocytosis have been reported (see Specific serious and/or common adverse reactions).

Immune system disorders: uncommon – allergic reactions, excluding anaphylactic or anaphylactoid reactions; not known – anaphylactic reaction, anaphylactoid reaction, including shock.

Psychiatric disorders: rare – mood changes, nightmares; not known – confusion, disorientation, insomnia.

Nervous system disorders: common – headache; uncommon – dizziness, somnolence.

Eye disorders: rare – visual disturbances including blurred vision; conjunctivitis.

Ear and labyrinth disorders: uncommon – dizziness; rare – tinnitus.

Cardiac disorders: rare – palpitations.

Heart failure associated with NSAID treatment has been reported.

Vascular disorders: uncommon – increased blood pressure (see section "Special precautions"), flushing.

Respiratory, thoracic and mediastinal disorders: rare – asthma in patients with aspirin or other NSAID allergy; not known – upper respiratory tract infections, cough.

Gastrointestinal disorders: very common – gastrointestinal disorders: dyspepsia, nausea, vomiting, abdominal pain, constipation, flatulence, diarrhea; uncommon – occult or macroscopic gastrointestinal bleeding, stomatitis, gastritis, eructation; rare – colitis, gastroduodenal ulcer, esophagitis; very rare – gastrointestinal perforation; not known – pancreatitis.

Gastrointestinal bleeding, ulceration, or perforation may be severe and potentially fatal, especially in elderly patients (see section "Special precautions").

Hepatobiliary disorders: uncommon – liver function test abnormalities (e.g., increased transaminases or bilirubin); very rare – hepatitis; not known – jaundice, hepatic failure.

Skin and subcutaneous tissue disorders: uncommon – angioedema, pruritus, rash; rare – Stevens-Johnson syndrome, toxic epidermal necrolysis, urticaria; very rare – bullous dermatitis, erythema multiforme; not known – photosensitivity reactions, exfoliative dermatitis, fixed drug eruption (see section "Special precautions").

Renal and urinary disorders: uncommon – sodium and water retention, hyperkalemia (see sections "Special precautions" and "Interaction with other medicinal products and other forms of interaction"), changes in renal function parameters (increased serum creatinine and/or urea); very rare – acute renal failure, particularly in patients with risk factors (see section "Special precautions"); not known – urinary tract infections, changes in micturition frequency.

Reproductive system and breast disorders: not known – female infertility, ovulation delay.

General disorders and administration site conditions: uncommon – edema, including peripheral edema; not known – influenza-like symptoms.

Musculoskeletal and connective tissue disorders: not known – arthralgia, back pain, joint-related signs and symptoms.

Specific serious and/or common adverse reactions. Very rare cases of agranulocytosis have been reported in patients treated with meloxicam and other potentially myelotoxic medicinal products (see section "Interaction with other medicinal products and other forms of interaction").

Adverse reactions not observed during drug use but generally recognized as characteristic of other compounds in the class. Organic kidney damage, which may lead to acute renal failure: very rare cases of interstitial nephritis, acute tubular necrosis, nephrotic syndrome, and papillary necrosis have been reported (see section "Special precautions").

Reporting suspected adverse reactions. Reporting suspected adverse reactions after drug authorization is important. It allows continued monitoring of the benefit-risk balance of the medicinal product. Healthcare professionals, pharmacists, patients, and their legal representatives should report all suspected adverse reactions and lack of efficacy through the Automated Pharmacovigilance Information System at the following link: https://aisf.dec.gov.ua.

Shelf life. 2 years.

Storage conditions. Store at a temperature not exceeding 25 °C in the original packaging, in a place inaccessible to children.

Packaging. 10 tablets in a blister pack; 1 blister pack in a cardboard box.

Prescription status. Prescription only.

Manufacturer. Medochemie Ltd (Central Factory).

Manufacturer's address.
1-10 Constantinoupoleos Street, Limassol, 3011, Cyprus.