piroxicam

Absorption: Well absorbed from the GI tract.

Distribution: Unknown. Enters breast milk in small amounts.

Metabolism/Excretion: Mostly metabolized by the liver primarily by the CYP2C9 isoenzyme. Patients who are poor CYP2C9 metabolizers may have reduced metabolism of piroxicam, which may lead to ↑ toxicity. Minimal amounts excreted unchanged by the kidneys.

Half-Life: 50 hr.

Time/Action Profile ⬆ ⬇

ROUTE	ONSET	PEAK	DURATION
PO (analgesic effect)	1 hr	unknown	48–72 hr
PO (anti-inflammatory effect)	7–12 days	2–3 wk‡	unknown

‡May take up to 12 wk.

Contraind./Precautions ⬆ ⬇

Contraindicated in:

Hypersensitivity;
Cross-sensitivity may exist with other NSAIDs, including aspirin;
Active GI bleeding or ulcer disease;
Coronary artery bypass graft surgery;
OB: Pregnancy after 30 wk gestation;
Lactation: Lactation.

Use Cautiously in:

Cardiovascular disease or risk factors for cardiovascular disease (may ↑ risk of serious cardiovascular thrombotic events, myocardial infarction, and stroke, especially with prolonged use or use of higher doses); avoid use in patients with recent MI or HF;
History of peptic ulcer disease and/or GI bleed, smoking, alcohol use, severe hepatic impairment, coagulopathy, and poor general health status (↑ risk of GI bleeding);
Renal impairment (dosage ↓ recommended);
Poor CYP2C9 metabolizers (↑ risk of toxicity);
OB: Pregnancy between 20 wk and 30 wk gestation;
Pedi: Safety and effectiveness not established in children;
Geri: Appears on Beers list. risk GI bleeding or peptic ulcer disease in older adults. Avoid chronic use unless other alternatives are not effective and the patient can take a gastroprotective agent; avoid short-term use in combination with oral or parenteral corticosteroids, anticoagulants, or antiplatelet agents unless other alternatives are not effective and the patient can take a gastroprotective agent.

Adv. Reactions/Side Effects ⬆ ⬇

CV: edema, HF, hypertension, MI

Derm: DRUG REACTION WITH EOSINOPHILIA AND SYSTEMIC SYMPTOMS (DRESS), EXFOLIATIVE DERMATITIS, rash, STEVENS-JOHNSON SYNDROME (SJS), TOXIC EPIDERMAL NECROLYSIS

EENT: blurred vision, tinnitus

F and E: hyperkalemia

GI: discomfort, dyspepsia, nausea, vomiting, anorexia, constipation, diarrhea, flatulence, GI BLEEDING, HEPATOTOXICITY

GU: renal failure

Hemat: blood dyscrasias, prolonged bleeding time

Neuro: drowsiness, headache, dizziness, STROKE

Misc: HYPERSENSITIVITY REACTIONS (INCLUDING ANAPHYLAXIS)

Interactions ⬆ ⬇

Drug-drug:

Concurrent use with aspirin↓ levels and may ↓ effectiveness.
↑risk of bleeding with anticoagulants, aspirin, clopidogrel, ticagrelor, prasugrel, corticosteroids, fibrinolytics, selective serotonin reuptake inhibitors, orserotonin norepinephrine reuptake inhibitors.
↑adverse GI side effects with aspirin, corticosteroids, and other NSAIDs.
Probenecid↑ levels and may ↑ toxicity.
May ↓ response to antihypertensives or diuretics.
May ↑ serum levels and risk of toxicity from lithium and methotrexate.
May ↑ risk of hypoglycemia from insulin or oral hypoglycemic agents.
↑risk of adverse renal effects with cyclosporine, ACE inhibitors, or chronic use of acetaminophen.
May ↑ risk of hematologic toxicity from antineoplastics or radiation therapy.

Drug-Natural Products:

↑bleeding risk with arnica, chamomile, clove, dong quai, fenugreek, feverfew, garlic, ginger, ginkgo, and Panax ginseng.

Route/Dosage ⬆ ⬇

PO (Adults ): Anti-inflammatory: 10–20 mg/day; may be given as single dose or 2 divided doses. Antidysmenorrheal: 40 mg initially, then 20 mg/day.
PO Geriatric Patients ): 10 mg once daily initially.

Availability ⬆ ⬇

(Generic available)

Capsules: 10 mg; 20 mg

Assessment ⬆ ⬇

Assess pain and range of motion prior to administration, 1–2 hr following administration, and periodically during therapy.
Patients who have asthma, aspirin-induced allergy, and nasal polyps are at increased risk for developing hypersensitivity reactions. Monitor for rhinitis, asthma, and urticaria.
Assess for rash periodically during therapy. May cause SJS. Discontinue therapy if severe or if accompanied with fever, general malaise, fatigue, muscle or joint aches, blisters, oral lesions, conjunctivitis, hepatitis, and/or eosinophilia.
Monitor for signs and symptoms of DRESS (fever, rash, lymphadenopathy, facial swelling, eosinophilia) periodically during therapy. If symptoms occur, discontinue piroxicam.
Monitor BP during initiation and periodically during therapy. May cause fluid retention and edema leading to new onset or worsening hypertension.
Arthritis: Assess range of motion periodically during therapy.

Lab Test Considerations:

Bleeding time may be prolonged for up to 2 wk following discontinuation of therapy.
- May cause ↓ hemoglobin, hematocrit, leukocyte, and platelet counts.
- Monitor liver function tests periodically during therapy. May cause ↑ serum alkaline phosphatase, LDH, AST, and ALT concentrations.
- Monitor BUN, serum creatinine, and electrolytes periodically during therapy. May cause ↑ BUN, serum creatinine, and electrolyte concentrations and ↓ urine electrolyte concentrations.

Implementation ⬆ ⬇

Do not confuse piroxicam with paroxetine.
Administration in higher than recommended doses does not provide increased effectiveness but may cause increased side effects, especially in geriatric patients. Use lowest effective dose for shortest period of time to minimize risk of cardiovascular thrombotic events.
PO: Administer after meals or with food or an antacid containing aluminum or magnesium to minimize gastric irritation.
Administer as soon as possible after onset of menses. Prophylactic use has not been proved effective.

Patient/Family Teaching ⬆ ⬇

Advise patient to take this medication with a full glass of water and to remain in an upright position for 15–30 min after administration.
Instruct patient to take medication as directed. Take missed doses as soon as remembered but not if almost time for the next dose. Do not double doses.
May cause drowsiness or dizziness. Advise patient to avoid driving or other activities requiring alertness until response to the medication is known.
Caution patient to avoid the concurrent use of alcohol, aspirin, acetaminophen, or other OTC or herbal products without consulting health care professional.
Advise patient to inform health care professional of medication regimen prior to treatment or surgery.
Caution patient to use sunscreen and protective clothing to prevent photosensitivity reaction (rare).
Advise patient to consult health care professional if rash, itching, visual disturbances, tinnitus, weight gain, edema, black stools, persistent headache, influenza-like syndrome (chills, fever, muscle aches, pain), or hepatotoxicity (nausea, fatigue, lethargy, diarrhea, pruritus, jaundice, right upper quadrant tenderness, flu-like symptoms) occur.
Rep: May cause fetal harm. Advise females of reproductive potential to notify health care professional if pregnancy is planned or suspected and to avoid ibuprofen starting at 20 wk gestation due to risk of oligohydramnios and 30 wk gestation because of risk of premature closing of the fetal ductus arteriosus. If NSAIDs are necessary between 20 and 30 wk gestation, limit use to the lowest effective dose and shortest duration possible. Consider ultrasound monitoring of amniotic fluid if NSAID therapy extends beyond 48 hr. Discontinue piroxicam if oligohydramnios occurs and follow up with infant. Advise women to avoid piroxicam in the 3rd trimester of pregnancy (after 29 wk); may cause premature closure of the fetal ductus arteriosus. Use during labor or delivery may delay birth and increase risk of stillbirth. Advise patient to notify health care professional if breastfeeding. May cause temporary infertility in women.

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Pronunciation ⬇

Classifications ⬆ ⬇

Indications ⬆ ⬇

Action ⬆ ⬇

Pharmacokinetics ⬆ ⬇