- Short-term symptomatic treatment of exacerbations of osteoarthrosis.
- Long-term symptomatic treatment of rheumatoid arthritis or ankylosing spondylitis.

Oral use
The total daily amount should be taken as a single dose, with water or another liquid, during a meal.
Undesirable effects may be minimised by using the lowest effective dose for the shortest duration necessary to control symptoms . The patient's need for symptomatic relief and response to therapy should be re-evaluated periodically, especially in patients with osteoarthritis.
- Exacerbations of osteoarthrosis: 7.5 mg/day (one 7.5 mg tablet, half a 15 mg tablet). If necessary, in the absence of improvement, the dose may be increased to 15 mg/day (two 7.5 mg tablets).
- Rheumatoid arthritis, ankylosing spondylitis: 15 mg/day (two 7.5 mg tablets, one 15 mg tablet). According to the therapeutic response, the dose may be reduced to 7.5 mg/day (one 7.5 mg tablet, half a 15 mg tablet).
DO NOT EXCEED THE DOSE OF 15 MG/DAY.
Special populations
Elderly patients and patients with increased risks for adverse reaction : The recommended dose for long term treatment of rheumatoid arthritis and ankylosing spondylitis in elderly patients is 7.5 mg per day. Patients with increased risks for adverse reactions should start treatment with 7.5 mg per day .
Renal impairment:
In dialysis patients with severe renal failure, the dose should not exceed 7.5 mg per day. No dose reduction is required in patients with mild to moderate renal impairment (i.e. patients with a creatinine clearance of greater than 25 ml/min). (For patients with non-dialysed severe renal failure, 
Hepatic impairment :
No dose reduction is required in patients with mild to moderate hepatic impairment (For patients with severely impaired liver function,
Children and adolescents:
Selektine tablets is contraindicated in children and adolescents aged under 16 years ( see section 4.3 ).

This medicinal product exists in other dosages, which may be more appropriate.

This medicinal product is contra-indicated in the following situations: - Third trimester of pregnancy (see section 4.6 ‘Fertility, pregnancy and lactation’); children and adolescents aged under 16 years. - Hypersensitivity to meloxicam or to any of the excipients listed in section 6.1 or hypersensitivity to substances with a similar action, e.g. NSAIDs, aspirin. Meloxicam should not be given to patients who have developed signs of asthma, nasal polyps, angioneurotic edema or urticaria following the administration of aspirin or other NSAIDs. - history of gastrointestinal bleeding or perforation, related to previous NSAIDs therapy; - active, or history of recurrent peptic ulcer/haemorrhage (two or more distinct episodes ofproven ulceration or bleeding). - severely impaired liver function. - non-dialysed severe renal failure. - gastrointestinal bleeding, history of cerebrovascular bleeding or other bleeding disorders. - severe heart failure.

- Undesirable effects may be minimised by using the lowest effective dose for the shortest duration necessary to control symptoms .
The recommended maximum daily dose should not be exceeded in case of insufficient therapeutic effect, nor should an additional NSAID be added to the therapy because this may increase the toxicity while therapeutic advantage has not been proven. The use of meloxicam with concomitant NSAIDs including cyclooxygenase-2 selective inhibitors should be avoided. Meloxicam is not appropriate for the treatment of patients requiring relief from acute pain. In the absence of improvement after several days, the clinical benefit of the treatment should be reassessed.
- Any history of oesophagitis, gastritis and/or peptic ulcer must be sought in order to ensure their total cure before starting treatment with meloxicam. Attention should routinely be paid to the possible onset of a recurrence in patients treated with meloxicam and with a past history of this type.
Gastrointestinal effects
GI bleeding, ulceration or perforation, which can be fatal, has been reported with all NSAIDs at any time during treatment, with or without warning symptoms or a previous history of serious GI events.
The risk of GI bleeding, ulceration or perforation is higher with increasing NSAID doses, in patients with a history of ulcer, particularly if complicated with haemorrhage or perforation (see section 4.3), and in the elderly. These patients should commence treatment on the lowest dose available. Combination therapy with protective agents (e.g. misoprostol or proton pump inhibitors) should be considered for these patients, and also for patients requiring concomitant low dose aspirin, or other drugs likely to increase gastrointestinal risk (see section 4.5) .
Patients with a history of GI toxicity, particularly when elderly, should report any unusual abdominal symptoms (especially GI bleeding) particularly in the initial stages of treatment.
In patients receiving concomitant medications which could increase the risk of ulceration or bleeding, such as heparin as curative treatment or given in geriatrics, anticoagulants such as warfarin, other nonsteroidal anti-inflammatory drugs, or acetylsalicylic acid given at doses =500 mg as single intake or = 3g as total daily amount the combination with meloxicam is not recommended.
When GI bleeding or ulceration occurs in patients receiving meloxicam the treatment should be withdrawn.
NSAIDs should be given with care to patients with a history of gastrointestinal disease (ulcerative colitis, Crohn's disease) as these conditions may be exacerbated.
Cardiovascular and cerebrovascular effects
Appropriate monitoring and advice are required for patients with a history of hypertension and/or mild to moderate congestive heart failure as fluid retention and oedema have been reported in association with NSAID therapy.
Clinical monitoring of blood pressure for patients at risk is recommended at baseline and especially during treatment initiation with meloxicam.
Clinical trial and epidemiological data suggest that use of some NSAIDs including meloxicam (particularly at high doses and in long term treatment) may be associated with a small increased risk of arterial thrombotic events (for example myocardial infarction or stroke). There are insufficient data to exclude such a risk for meloxicam. Patients with uncontrolled hypertension, congestive heart failure, established ischaemic heart
disease, peripheral arterial disease, and/or cerebrovascular disease should only be treated with meloxicam after careful consideration. Similar consideration should be made before initiating longer-term treatment of patients with risk factors for cardiovascular disease (e.g. hypertension, hyperlipidaemia, diabetes mellitus, smoking).
Skin reactions
Life-threatening cutaneous reactions Stevens-Johnson syndrome (SJS) and toxic epidermal necrolysis (TEN) have been reported with the use of Meloxicam. Patients should be advised of the signs and symptoms and monitored closely for skin reactions. The highest risk for occurrence of
SJS or TEN is within the first weeks of treatment. If symptoms or signs of SJS or TEN (e.g. progressive skin rash often with blisters or mucosal lesions) are present, Meloxicam treatment should be discontinued. The best results in managing SJS and TEN come from early diagnosis and immediate discontinuation of any suspect drug. Early withdrawal is associated with a better prognosis. If the patient has developed SJS or TEN with the use of Meloxicam, Meloxicam must not be re-started in this patient at any time.
Parameters of liver and renal function
As with most NSAIDs, occasional increases in serum transaminase levels, increases in serum bilirubin or other liver function parameters, as well as increases in serum creatinine and blood urea nitrogen and other laboratory disturbances, have been reported. The majority of these instances involved transitory and slight abnormalities. Should any such abnormality prove significant or persistent, the administration of Meloxicam should be stopped and appropriate investigations undertaken.
Functional renal failure
NSAIDs, by inhibiting the vasodilating effect of renal prostaglandins, may induce a functional renal failure by reduction of glomerular filtration. This adverse event is dose-dependant. At the beginning of the treatment, or after dose increase, careful monitoring of diuresis and renal function is recommended in patients with the following risk factors:

•  Elderly.
• Concomitant treatments such as ACE inhibitors, angiotensin-II antagonists, sartans, diuretic.
• Hypovolemia (whatever the cause).
• Congestive heart failure.
• Renal failure.
• Nephrotic syndrome.
• Lupus nephropathy.
• Severe hepatic dysfunction (serum albumin <25 g/l or Child-Pugh score =10)

In rare instance NSAIDs may be the cause of interstitial nephritis, glomerulonephritis, renal medullary necrosis or nephrotic syndrome.
The dose of meloxicam in patients with end-stage renal failure on haemodialysis should not be higher than 7.5 mg. No dose reduction is required in patients with mild or moderate renal impairment (i.e. in patients with a creatinine clearance of greater than 25 ml/min).
Sodium, potassium and water retention
Induction of sodium, potassium and water retention and interference with the natriuretic effects ofdiuretics may occur with NSAIDs. Furthermore, a decrease of the antihypertensive effect of antihypertensive drugs can occur. Consequently, oedema, cardiac failure or hypertension may be precipitated or exacerbated in susceptible patients as a result. Clinical monitoring is therefore necessary for patients at risk.
Hyperkalaemia
Hyperkalaemia can be favoured by diabetes or concomitant treatment known to increase kalaemia. Regular monitoring of potassium values should be performed in such cases.

Combination with pemetrexed
In patients with mild to moderate renal insufficiency receiving pemetrexed, meloxicam should be interrupted for at least 5 days prior to, on the day of, and at least 2 days following pemetrexed administration.
Other warnings and precautions
Adverse reactions are often less well tolerated in elderly, fragile or weakened individuals, who therefore require careful monitoring. As with other NSAIDs, particular caution is required in the elderly, in whom renal, hepatic and cardiac functions are frequently impaired. The elderly have an increased frequency of adverse reactions to NSAIDs especially gastrointestinal bleeding and perforation which may be fatal. Meloxicam, as any other NSAID may mask symptoms of an underlying infectious disease.

 The use of meloxicam may impair female fertility and is not recommended in women attempting to conceive. In women who have difficulties conceiving or who are undergoing investigation of infertility, withdrawal of meloxicam should be considered.

Selektine tablets contain lactose. Patients with rare hereditary problems of galactose intolerance, the Lapp-lactase deficiency or glucose-galactose malabsorption should not take this medicine.

Interaction studies have only been performed in adults.
Risks related to hyperkalaemia:
Certain medicinal products or therapeutic groups may promote hyperkalaemia: potassium salts, potassium-sparing diuretics, angiotensin-converting enzyme (ACE) inhibitors, angiotensin II receptor antagonists, non-steroidal anti-inflammatory drugs, (low-molecular-weight or unfractionated) heparins, cyclosporin, tacrolimus and trimethoprim.
The onset of hyperkalaemia may depend on whether there are associated factors.

This risk is increased when the above-mentioned medicinal products are co-administered with meloxicam.

Fertility
The use of meloxicam, as with any drug known to inhibit cyclooxygenase/prostaglandin synthesis, may impair female fertility and is not recommended in women attempting to conceive. In women who have difficulties conceiving or who are undergoing investigation of infertility, withdrawal of meloxicam should be considered.
Pregnancy
Inhibition of prostaglandin synthesis may adversely affect the pregnancy and/or the embryo/foetal development. Data from epidemiological studies suggest an increased risk of miscarriage and of cardiac malformation and gastroschisis after use of a prostaglandin synthesis inhibitor in early
pregnancy. The absolute risk for cardiovascular malformation was increased from less than 1%, up to approximately 1.5 %. The risk is believed to increase with dose and duration of therapy. In animals, administration of a prostaglandin synthesis inhibitor has been shown to result in increased pre- and post-implantation loss and embryo-foetal lethality. In addition, increased incidences of various malformations, including cardiovascular, have been reported in animals given a prostaglandin synthesis inhibitor during the organogenetic period.
During the first and second trimester of pregnancy, meloxicam should not be given unless clearly necessary. If meloxicam is used by a woman attempting to conceive, or during the first and second trimester of pregnancy, the dose should be kept as low and duration of treatment as short as
possible.
During the third trimester of pregnancy, all prostaglandin synthesis inhibitors may expose
- The foetus to:

• Cardiopulmonary toxicity (with premature closure of the ductus arteriosus and pulmonary hypertension).
• Renal dysfunction, which may progress to renal failure with oligo-hydroamniosis.

         -  The mother and the neonate, at the end of pregnancy, to:

• Possible prolongation of bleeding time, an anti-aggregating effect which may occur even at very low doses.
• Inhibition of uterine contractions resulting in delayed or prolonged labour.

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

Lactation
While no specific experience exists for meloxicam, NSAIDs are known to pass into mother's milk. Administration therefore is not recommended in women who are breastfeeding.

 

No specific studies on the effect on the ability to drive and use machineries have been performed. However, on the basis of the pharmacodynamic profile and reported adverse drug reactions, meloxicam is likely to have no or negligible influence on these abilities. However, when visual
disturbances including blurred vision, dizziness, drowsiness, vertigo or other central nervous system disturbances occur, it is advisable to refrain from driving and operating machinery.

a) General Description
Clinical trial and epidemiological data suggest that use of some NSAIDs (particularly at high doses and in long term treatment) may be associated with a small increased risk of arterial thrombotic events (for example myocardial infarction or stroke) (see section 4.4).

Oedema, hypertension, and cardiac failure, have been reported in association with NSAID treatment.
The most commonly-observed adverse events are gastrointestinal in nature. Peptic ulcers, perforation or GI bleeding, sometimes fatal, particularly in the elderly, may occur(see section 4.4). . Nausea, vomiting, diarrhoea, flatulence, constipation, dyspepsia, abdominal pain, melaena, haematemesis, ulcerative stomatitis, exacerbation of colitis and Crohn's disease(see section 4.4).have been reported following administration. Less frequently, gastritis has been observed.
Severe cutaneous adverse reactions (SCARs): Stevens-Johnson syndrome (SJS) and toxic epidermal necrolysis (TEN) have been reported(see section 4.4).
The frequencies of adverse drug reactions given below are based on corresponding occurrences of reported adverse events in 27 clinical trials with a treatment duration of at least 14 days. The information is based on clinical trials involving 15197 patients who have been treated with daily oral doses of 7.5 or 15 mg meloxicam tablets or capsules over a period of up to one year.

Adverse drug reactions that have come to light as a result of reports received in relation to administration of the marketed product are included.
Adverse reactions have been ranked under headings of frequency using the following convention:
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)
b) Table of adverse reactions
Blood and lymphatic system disorders
Uncommon: Anaemia.
Rare: Blood count abnormal (including differential white cell count), leukopenia, thrombocytopenia.
Very rare cases of agranulocytosis have been reported.
Immune system disorders
Uncommon: Allergic reactions other than anaphylactic or anaphylactoid reactions
Psychiatric disorders
Rare: Mood altered, nightmares
Nervous system disorders
Common: Headache
Uncommon: Dizziness, somnolence
Eye disorders
Rare: Visual disturbance including vision blurred; conjunctivitis
Ear and labyrinth disorders
Uncommon: Vertigo
Rare: Tinnitus
Cardiac disorders
Rare: Palpitations.
Cardiac failure has been reported in association with NSAID treatment.
Vascular disorders
Uncommon: Blood pressure increased (see section 4.4), flushing.
Respiratory, thoracic and mediastinal disorders.
Rare: Asthma in individuals allergic to aspirin or other NSAIDs.
Gastrointestinal disorders
Very common: Gastrointestinal disorders such as dyspepsia, nausea, vomiting, abdominal pain, constipation, flatulence, diarrhoea
Uncommon: Occult or macroscopic gastrointestinal haemorrhage, stomatitis, gastritis, eructation
Rare: Colitis, gastroduodenal ulcer, oesophagitis
Very rare: Gastrointestinal perforation
Gastrointestinal haemorrhage, ulceration or perforation may sometimes be severe and potentially fatal, especially in elderly.
Hepatobiliary disorders
Uncommon: Liver function disorder (e.g. raised transaminases or bilirubin)
Very rare: Hepatitis
Skin and subcutaneous tissue disorders
Uncommon: Angioedema, pruritus, rash
Rare: Stevens-Johnson syndrome, toxic epidermal necrolysis, urticaria
Very rare: Dermatitis bullous, erythema multiforme
Renal and urinary disorders
Uncommon: Sodium and water retention, hyperkalaemia, renal function test abnormal (increased serum creatinine
and/or serum urea)
Very rare: Acute renal failure in particular in patients with risk factors
General disorders and administration site conditions
Uncommon: Oedema including oedema of the lower limbs.
c) Information Characterising Individual Serious and/or Frequently Occurring Adverse
Reactions
Very rare cases of agranulocytosis have been reported in patients treated with meloxicam and other potentially myelotoxic drugs .
d) Adverse reactions which have not been observed yet in relation to the product, but which are generally accepted as being attributable to other compounds in the class
Organic renal injury probably resulting in acute renal failure: very rare cases of interstitial nephritis, acute tubular necrosis, nephrotic syndrome, and papillary necrosis have been reported (see section 4.4).

Symptoms following acute NSAID overdose are usually limited to lethargy, drowsiness, nausea, vomiting and epigastric pain, which are generally reversible with supportive care. Gastrointestinal bleeding can occur. Severe poisoning may result in hypertension, acute renal failure, hepatic dysfunction, respiratory depression, coma, convulsions, cardiovascular collapse and cardiac arrest. Anaphylactoid reactions have been reported with therapeutic ingestion of NSAIDs and may occur following an overdose.
Patients should be managed with symptomatic and supportive care following an NSAID overdose.
Accelerated removal of meloxicam by 4 g oral doses of cholestyramine given three times a day was demonstrated in a clinical trial.

 

Pharmacotherapeutic group: Non-Steroidal Anti-Inflammatory agent, Oxicams, ATC code: M01AC06
Meloxicam is a non-steroidal anti-inflammatory drug (NSAID) of the oxicam family, with antiinflammatory, analgesic and antipyretic properties.
The anti-inflammatory activity of meloxicam has been proven in classical models of inflammation.
As with other NSAIDs, its precise mechanism of action remains unknown. However, there is at least one common mode of action shared by all NSAIDs (including Meloxicam): inhibition of the biosynthesis of prostaglandins, known inflammation mediators.

Absorption
Meloxicam is well absorbed from the gastrointestinal tract, which is reflected by a high absolute
bioavailability of about 90% following oral administration (capsule). Tablets, oral suspension and
capsules were shown to be bioequivalent.
Following single dose administration of meloxicam, median maximum plasma concentrations are
achieved within 2 hours for the suspension and within 5-6 hours with solid oral dosage forms
(capsules and tablets).
With multiple dosing, steady state conditions were reached within 3 to 5 days. Once daily dosing
leads to mean drug plasma concentrations with a relatively small peak-trough fluctuation in the
range of 0.4 - 1.0 μg/mL for 7.5 mg doses and 0.8 - 2.0 μg/mL for 15 mg doses, respectively (Cmin
and Cmax at steady state, correspondingly). Mean maximum plasma concentrations of meloxicam
at steady state are achieved within five to six hours for the tablet, capsule and the oral suspension,
respectively. Extent of absorption for meloxicam following oral administration is not altered by
concomitant food intake or the use of inorganic antacids.
Distribution
Meloxicam is very strongly bound to plasma proteins, essentially albumin (99%). Meloxicam
penetrates into synovial fluid to give concentrations approximately half of those in plasma.
Volume of distribution is low, i.e. approx. 11 L after i.m. or i.v. administration, and shows
interindividual variation in the order of 7 - 20%. The volume of distribution following administration
of multiple oral doses of meloxicam (7.5 to 15 mg) is about 16 L with coefficients of variation
ranging from 11 to 32%.
Biotransformation
Meloxicam undergoes extensive hepatic biotransformation. Four different metabolites of
meloxicam were identified in urine, which are all pharmacodynamically inactive. The major
metabolite, 5'-carboxymeloxicam (60% of dose), is formed by oxidation of an intermediate
metabolite 5'-hydroxymethylmeloxicam, which is also excreted to a lesser extent (9% of dose). In
vitro studies suggest that CYP 2C9 plays an important role in this metabolic pathway, with a minor
contribution from the CYP 3A4 isoenzyme. The patient's peroxidase activity is probably
responsible for the other two metabolites, which account for 16% and 4% of the administered dose
respectively.
Elimination
Meloxicam is excreted predominantly in the form of metabolites and occurs to equal extents in
urine and faeces. Less than 5% of the daily dose is excreted unchanged in faeces, while only
traces of the parent compound are excreted in urine.
The mean elimination half-life varies between 13 and 25 hours after oral, i.m. and i.v.
administration. Total plasma clearance amounts about 7 – 12 mL/min following single doses orally,
intravenously or rectally administered.
Linearity/non-linearity
Meloxicam demonstrates linear pharmacokinetics in the therapeutic dose range of 7.5 mg 15 mg
following per oral or intramuscular administration.
Special populations
Patients with hepatic/renal insufficiency:
Neither hepatic, nor mild to moderate renal insufficiency has a substantial effect on meloxicam
pharmacokinetics. Subjects with moderate renal impairment had significant higher total drug
clearance. A reduced protein binding is observed in patients with terminal renal failure. In terminal
renal failure, the increase in the volume of distribution may result in higher free meloxicam
concentrations, and a daily dose of 7.5 mg must not be exceeded (see section 4.2).
Elderly:
Elderly male subjects exhibited similar mean pharmacokinetic parameters compared to those of
young male subjects.
Elderly female patients showed higher AUC-values and longer elimination half-lives compared to
those of young subjects of both genders. Mean plasma clearance at steady state in elderly
subjects was slightly lower than that reported for younger subjects.

The toxicological profile of meloxicam has been found in preclinical studies to be identical to that of NSAIDs: gastrointestinal ulcers and erosions, renal papillary necrosis at high doses during chronic administration in two animal species.
Oral reproductive studies in the rat have shown a decrease of ovulations and inhibition of implantations and embryotoxic effects (increase of resorptions) at maternotoxic dose levels at 1mg/kg and higher. Studies of toxicity on reproduction in rats and rabbits did not reveal teratogenicity up to oral doses of 4 mg/kg in rats and 80 mg/kg in rabbits.
The affected dose levels exceeded the clinical dose (7.5-15 mg) by a factor of 10 to 5-fold on a mg/kg dose basis (75 kg person). Fetotoxic effects at the end of gestation, shared by all prostaglandin synthesis inhibitors, have been described.
No evidence has been found of any mutagenic effect, either in vitro or in vivo. No carcinogenic risk has been found in the rat and mouse at doses far higher than those used clinically.

• Croscarmellose sodium.
• Lactose monohydrate.
• Microcrystalline cellulose.
• Colloidal anhydrous silica.
• Sodium laurilsulfate.
• Magnesium stearate.

Not applicable.

36 months

Store in the original package, in order to protect from moisture.

PVC/Aluminum blisters containing tablets.
Pack size for 7.5 mg tablets: 30 as commercially available.
Pack size for 15 mg tablets: 30 as commercially available.

No special requirements.