Meloxicam-teva

INSTRUCTION FOR MEDICINAL USE OF MELOXICAM-TEVA (Meloxicam-TEVA)

Composition:

Active substance: meloxicam;

One ampoule (1.5 ml) contains 15 mg of meloxicam;

Excipients: meglumine, glycofurol, poloxamer 188, sodium chloride, glycine, sodium hydroxide, water for injections.

Pharmaceutical form. Injection solution.

Main physicochemical properties: clear yellow solution with a greenish tint, practically free from foreign particles, in ampoules made of colorless glass.

Pharmacotherapeutic group. Non-steroidal anti-inflammatory and antirheumatic agents. Oxicams. ATC code M01A C06.

Pharmacological properties.

Pharmacodynamics.

Meloxicam is a non-steroidal anti-inflammatory drug (NSAID) from the oxicam group, with anti-inflammatory, analgesic, and antipyretic properties. Meloxicam has demonstrated high anti-inflammatory activity in all standard models of inflammation. As with other NSAIDs, its precise 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 completely absorbed after intramuscular injection. The relative bioavailability compared to oral administration is nearly 100%. Therefore, dose adjustment is not required when switching from intramuscular to oral administration. After intramuscular injection of 15 mg, the maximum plasma concentration reaches approximately 1.6–1.8 µg/mL and is achieved within 1–6 hours.

Distribution. Meloxicam is highly bound to plasma proteins, primarily to albumin (99%). Meloxicam penetrates into synovial fluid, where its concentration is about half that in blood plasma. The volume of distribution is low, averaging 11 L after intramuscular or intravenous administration, with individual variations within 7–20%. 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, which are 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 also excreted to a lesser extent (9% of dose). In vitro studies suggest that CYP 2C9 plays a major role in the metabolic process, while CYP 3A4 isoenzymes play a minor role. Peroxidase activity in patients may be responsible for two other metabolites, accounting for 16% and 4% of the administered dose, respectively.

Elimination. Elimination of meloxicam occurs primarily in the form of metabolites, in equal parts via 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, depending on the route of administration (oral, intramuscular, or intravenous). Plasma clearance is approximately 7–12 mL/min after a single oral, intravenous, or rectal dose.

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 had 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 increased free meloxicam concentration (see sections "Contraindications" and "Dosage and administration").

Elderly patients. In elderly male patients, mean 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. Mean plasma clearance at steady state in elderly patients was slightly lower than in young volunteers.

Clinical characteristics.

Indications.

Short-term symptomatic treatment of acute attacks of rheumatoid arthritis and ankylosing spondylitis when other routes of administration cannot be used. Meloxicam-Teva, solution for injection, is indicated for treatment of adults.

Contraindications.

• Hypersensitivity to meloxicam or to any of the excipients;
• Hypersensitivity to active substances with similar actions, such as NSAIDs, aspirin. Meloxicam should not be administered to patients who experience asthma symptoms, nasal polyps, angioedema, or urticaria after taking aspirin or other NSAIDs;
• Third trimester of pregnancy (see section "Use during pregnancy or breastfeeding");
• Patient age under 18 years;
• Gastrointestinal bleeding or perforation related to previous NSAID therapy in medical history;
• Active or recurrent peptic ulcer/bleeding in medical history (two or more separate confirmed episodes of ulcer or bleeding);
• Severe hepatic insufficiency;
• Severe renal insufficiency without dialysis;
• Gastrointestinal bleeding, cerebrovascular bleeding in medical history, or other coagulation disorders;
• Hemostasis disorders or concomitant use of anticoagulants (contraindications related to the route of administration);
• Severe heart failure;
• Treatment of perioperative pain in coronary artery bypass grafting (CABG).

Interaction with other medicinal products and other forms of interaction.

Risks associated with hyperkalemia. Certain medicinal products or therapeutic groups may contribute to hyperkalemia: potassium salts, potassium-sparing diuretics, angiotensin-converting enzyme (ACE) inhibitors, angiotensin II receptor antagonists, nonsteroidal anti-inflammatory drugs (NSAIDs), (low molecular weight or unfractionated) heparins, cyclosporine, tacrolimus, and trimethoprim. The onset of hyperkalemia may depend on associated factors. The risk of hyperkalemia increases if the above-mentioned 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"), as well as with acetylsalicylic acid at doses ≥500 mg per dose or ≥3 g total daily dose.

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

Anticoagulants or heparin. Significantly increases the risk of bleeding due to inhibition of platelet function and damage to the gastroduodenal mucosa. 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. Due to intramuscular administration, meloxicam injection solution is contraindicated in patients undergoing treatment with anticoagulants (see sections "Contraindications" and "Special precautions for use"). In other cases (e.g., prophylactic doses), caution is required when using heparin due to increased risk of bleeding.

Thrombolytics and antiplatelet agents. Increased risk of bleeding due to 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 efficacy of diuretics and other antihypertensive medicinal products. In some patients with impaired renal function (e.g., dehydrated patients or elderly patients with impaired renal function), 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 combined therapy and periodically thereafter (see section "Special precautions for use").

Other antihypertensive medicinal products (e.g., beta-blockers). As with the use of the following medicinal products, a reduction in the antihypertensive effect of beta-blockers is possible (due to inhibition of vasodilatory prostaglandins).

Calcineurin inhibitors (e.g., cyclosporine, tacrolimus). The nephrotoxicity of calcineurin inhibitors may be enhanced 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 exist for NSAIDs increasing 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 beginning of treatment, during dose adjustment, and upon discontinuation of meloxicam.

Methotrexate. 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 parameters and renal function should be monitored. Caution is advised if NSAID and methotrexate administration continues for 3 consecutive days, as methotrexate plasma levels may increase and enhance toxicity. Although the pharmacokinetics of methotrexate (15 mg/week) were not affected by concomitant treatment with meloxicam, hematological toxicity of methotrexate may increase during NSAID treatment (see 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 withheld for 5 days before, on the day of, and for 2 days after pemetrexed administration. If combination of meloxicam with pemetrexed is necessary, patients should be closely monitored, particularly for signs of 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), 15 mg doses 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. 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 combination of meloxicam and other medicinal products on pharmacokinetics

Oral antidiabetic agents (sulfonylureas, nateglinide). Meloxicam is almost entirely eliminated via hepatic metabolism, approximately two-thirds mediated by cytochrome P450 (CYP) enzymes (mainly CYP 2C9 and minor pathway 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 clearly inhibit or are metabolized by CYP 2C9 and/or CYP 3A4. Interactions mediated by CYP 2C9 may be expected in combination with medicinal products such as oral antidiabetics (sulfonylureas, nateglinide); this interaction may lead to increased plasma levels of both agents. 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 use of antacids, cimetidine, and 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 the therapeutic effect is inadequate, 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 should not be used for the treatment of patients requiring relief of acute pain. In the absence of improvement after several days, the clinical benefit of treatment should be re-evaluated.

Particular attention should be paid to a history of esophagitis, gastritis and/or peptic ulcer to ensure 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 is higher with increased NSAID doses in patients with a history of ulcer, 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 drugs 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 any unusual abdominal symptoms (particularly gastrointestinal bleeding), especially in the initial stages of treatment. Use of meloxicam is not recommended for patients receiving concomitant medications that may increase the risk of ulceration or bleeding, such as heparin, as radical therapy or in geriatric practice, or other non-steroidal anti-inflammatory drugs, or 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 "Undesirable effects").

Hepatic disorders. In patients taking NSAIDs (including meloxicam), elevation of one or more liver function tests may occur. Such laboratory abnormalities may progress, remain unchanged, or be transient during continued treatment. Elevation of alanine aminotransferase (ALT) or aspartate aminotransferase (AST) (approximately 3 times or more above normal) may occur. Rare cases of severe hepatic reactions, including jaundice and fulminant fatal hepatitis, liver necrosis, and hepatic failure, some with fatal outcome, have been reported. Patients with symptoms and/or signs of hepatic dysfunction or with abnormal liver function tests should be evaluated for the development of more severe hepatic failure during meloxicam therapy. If clinical signs and symptoms are associated with the development of liver disease or if systemic manifestations of disease (e.g., eosinophilia, rash, and others) are observed, meloxicam use should be discontinued.

Cardiovascular and cerebrovascular disorders. Careful monitoring is recommended for patients with arterial hypertension and/or a history of 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 start of therapy, especially at the beginning of meloxicam treatment, for patients with risk factors.

Data from studies and epidemiological data suggest that the use of certain NSAIDs, including meloxicam (especially 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 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 (e.g., arterial hypertension, hyperlipidemia, diabetes mellitus, smokers).

NSAIDs may increase the risk of serious cardiovascular thrombotic events, myocardial infarction, and stroke, which may be fatal. The risk increases with duration of use. Patients with cardiovascular disease or cardiovascular risk factors may have an increased risk of thrombotic complications.

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 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 important to diagnose and discontinue any drugs that may cause severe skin reactions—Stevens–Johnson syndrome or toxic epidermal necrolysis—as early as possible, as this is associated with a better prognosis in severe skin reactions. If a patient develops Stevens–Johnson syndrome or toxic epidermal necrolysis while taking meloxicam, the drug must never be restarted 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. Potential cross-reactivity may occur with other oxicams.

Anaphylactoid reactions. As with other NSAIDs, anaphylactoid reactions may occur in patients without known sensitivity to meloxicam. The drug should not be used in patients with aspirin triad. This syndrome complex occurs in patients with asthma who have a history of rhinitis with or without nasal polyps or who experienced severe, potentially fatal bronchospasm after taking aspirin or other NSAIDs. Immediate measures should be taken if an anaphylactoid reaction occurs.

Liver parameters and kidney function. As with treatment with most NSAIDs, isolated cases of elevated serum transaminases, serum bilirubin levels, or other liver function parameters, increased serum creatinine and blood urea nitrogen, and other laboratory parameter deviations have been described. In most cases, these deviations were minor and transient. If significant or persistent abnormalities are confirmed, meloxicam use should be discontinued and follow-up tests performed.

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 renal function, including urine output, is recommended at the beginning of treatment or after dose increase in patients with risk factors such as advanced age; concomitant use with ACE inhibitors, angiotensin II antagonists, sartans, or 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 nephritis; or 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 in patients with end-stage renal failure on dialysis should not exceed 7.5 mg. Dose reduction is not required 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. In addition, a reduction in the antihypertensive effect of antihypertensive drugs may occur (see section "Interaction with other medicinal products and other forms of interaction"). Consequently, edema, heart failure, or arterial hypertension may be accelerated or exacerbated in susceptible patients. Therefore, clinical monitoring is recommended for such patients (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"). In such cases, regular monitoring of potassium levels is required.

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

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

Glucocorticoid therapy. Meloxicam cannot be considered a substitute for glucocorticoids in the treatment of glucocorticoid deficiency.

Hematological effects. Anemia may occur in patients receiving NSAIDs, including meloxicam. This may be related to fluid retention, gastrointestinal bleeding of unknown origin or macroscopic bleeding, or incompletely described effects on erythropoiesis. Patients undergoing long-term NSAID treatment, 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, short-term, and reversible. Patients taking meloxicam who may have adverse effects related to changes in platelet function, including coagulation disorders, or patients receiving anticoagulants, should be carefully monitored.

Use in patients with asthma. Patients with asthma may have aspirin-sensitive asthma. 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 existing asthma.

Other warnings and safety measures. Adverse reactions are often less well tolerated in elderly, debilitated, or frail patients, who require careful monitoring. As with treatment with other NSAIDs, caution is required in elderly patients, in whom reduced kidney, liver, and heart function is more likely. Elderly patients have a higher frequency of adverse reactions to NSAIDs, especially gastrointestinal bleeding and perforation, 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 adversely 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"). As with intramuscular administration of other NSAIDs, abscess or necrosis may occur at the injection site.

This medicinal product contains less than 1 mmol of sodium (23 mg) per 1.5 mL vial, i.e., practically sodium-free.

Use during pregnancy or breastfeeding.

Pregnancy. Inhibition of prostaglandin synthesis may adversely affect pregnancy and/or embryofetal 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 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. In addition, in animals receiving a prostaglandin synthesis inhibitor during organogenesis, increased frequency of various developmental abnormalities, including cardiovascular, has been reported.

From the 20th week of pregnancy, use of meloxicam may cause oligohydramnios due to fetal renal dysfunction. This may occur shortly after starting treatment and is usually reversible after discontinuation. In addition, cases of ductus arteriosus constriction after treatment in the second trimester of pregnancy have been reported, most of which resolved after treatment discontinuation. Therefore, meloxicam should not be used during the first and second trimesters of pregnancy, except in cases of essential need. If a woman is trying to become pregnant or uses meloxicam during the first and second trimesters of pregnancy, dosing and duration of treatment should be as low as possible. After using meloxicam for several days starting from the 20th week of pregnancy, consideration should be given to prenatal monitoring for oligohydramnios and ductus arteriosus constriction. Meloxicam should be discontinued if oligohydramnios or ductus arteriosus constriction is detected.

During the third trimester of pregnancy, all prostaglandin synthesis inhibitors may pose the following risks: 1) risks to the fetus: cardiopulmonary toxicity (premature constriction/closure of the ductus arteriosus and pulmonary hypertension); renal dysfunction (see above); 2) risks to the mother at the end of pregnancy and to the newborn: potential prolongation of 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 (see section "Contraindications").

Breastfeeding. Although specific data on meloxicam are lacking, NSAIDs are known to pass into breast milk. Therefore, use is not recommended for breastfeeding women.

Fertility. Meloxicam, like other medicinal products that inhibit cyclooxygenase/prostaglandin synthesis, may adversely 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 influence reaction speed when driving or operating machinery.

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

Method of Administration and Dosage.

Dosage. One injection of 15 mg once daily. DO NOT EXCEED THE DOSE OF 15 MG/DAY. Treatment should be limited to one injection at the beginning of therapy, with a maximum duration of up to 2–3 days in justified exceptional cases (e.g., when other routes of administration are not possible). 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 treatment should be periodically evaluated.

Special patient populations

Elderly patients and patients at increased risk of adverse reactions. The recommended dose for elderly patients is 7.5 mg/day. 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 7.5 mg/day (half of a 1.5 ml ampoule) (see section "Special Warnings and Precautions for Use").

Renal impairment. In patients with end-stage renal disease undergoing hemodialysis, the dose should not exceed 7.5 mg/day (half of a 1.5 ml ampoule). Dose reduction is not required in patients with mild to moderate renal impairment (i.e., patients with creatinine clearance above 25 ml/min). For patients with severe renal impairment not undergoing dialysis, see section "Contraindications."

Hepatic impairment. Dose reduction is not required in patients with mild to moderate hepatic impairment. For patients with severe hepatic impairment, see section "Contraindications."

Method of administration. For intramuscular use. The drug should be administered by deep intramuscular injection into the upper outer quadrant of the buttock, strictly following aseptic technique. In case of repeated administration, the injection site should be alternated (left and right buttocks). Prior to injection, it is important to ensure that the needle tip is not within a blood vessel. The injection should be immediately discontinued if severe pain occurs during administration. In patients with a hip prosthesis, the injection should be administered into the opposite buttock.

Children.

The drug is contraindicated in children (under 18 years of age).

Overdose.

Symptoms of acute NSAID overdose are usually limited to lethargy, drowsiness, nausea, vomiting, and epigastric pain, which are generally reversible with supportive treatment. 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.

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.

Adverse Reactions

Data from studies and epidemiological evidence suggest that the use of certain NSAIDs (particularly at high doses and during long-term treatment) may be associated with a small increased risk of vascular thrombotic events (e.g., myocardial infarction or stroke) (see section "Special Warnings and Precautions for Use"). 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 Warnings and Precautions for Use"). Nausea, vomiting, diarrhea, flatulence, constipation, dyspepsia, abdominal pain, melena, hematemesis, ulcerative stomatitis, and exacerbations of colitis and Crohn’s disease have been reported following administration (see section "Special Warnings and Precautions for Use"). Gastritis has been observed less frequently. Serious skin reactions have been reported, including Stevens–Johnson syndrome and toxic epidermal necrolysis (see section "Special Warnings and Precautions for Use").

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

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

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

Psychiatric disorders: rare – mood changes, nightmares; frequency 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 use has been reported.

Vascular disorders: uncommon – increased blood pressure (see section "Special Warnings and Precautions for Use"), flushing.

Respiratory, thoracic and mediastinal disorders: rare – asthma in patients with hypersensitivity to acetylsalicylic acid and other NSAIDs; frequency not known – upper respiratory tract infections, cough.

Gastrointestinal disorders: very common – gastrointestinal disturbances (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; frequency not known – pancreatitis. Gastrointestinal bleeding, ulcers, or perforation may be severe and potentially fatal, particularly in elderly patients (see section "Special Warnings and Precautions for Use").

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

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

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

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

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

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

Selected 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 previously observed with this medicinal product but known to occur with other agents in this pharmacotherapeutic group. 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 Warnings and Precautions for Use").

Reporting suspected adverse reactions. All suspected adverse reactions and lack of efficacy should be reported via the following link: https://aisf.dec.gov.ua.

Shelf life. 3 years.

Storage conditions. Store at temperatures not exceeding 25 °C, in a place inaccessible to children.

Incompatibilities. The injectable solution must not be mixed with other medicinal products in the same syringe.

Packaging. 5 ampoules of 1.5 mL in a plastic container, in a cardboard box.

Prescription status. Prescription only.

Manufacturer. Help S.A.

Manufacturer's address and place of business.
Pedinion Ioanninon, Ioannina, 45500, Greece.