TABLE 3.

THERAPEUTIC RECOMMENDATIONS FOR MELOXICAM BASED ON CYP2C9 PHENOTYPE

Phenotype	Implication	Therapeutic Recommendation	Classification of Recommendation	Other Considerations
CYP2C9 Normal Metabolizer	Normal metabolism	Initiate therapy with recommended starting dose. In accordance with the prescribing information, use the lowest effective dosage for shortest duration consistent with individual patient treatment goals.	Strong
CYP2C9 Intermediate Metabolizer AS of 1.5	Mildly reduced metabolism	Initiate therapy with recommended starting dose. In accordance with the meloxicam prescribing information, use the lowest effective dosage for shortest duration consistent with individual patient treatment goals.	Moderate	IMs might have a higher than normal risk of adverse events especially in individuals with other factors affecting clearance of these drugs such as hepatic impairment or advanced age.
CYP2C9 Intermediate Metabolizer AS of 1	Moderately reduced metabolism; higher plasma concentrations may increase probability of toxicities	Initiate therapy with 50% of the lowest recommended starting dose. Titrate dose upward to clinical effect or 50% of the maximum recommended dose with caution. In accordance with the meloxicam prescribing information, use the lowest effective dosage for shortest duration consistent with individual patient treatment goals. Upward dose titration should not occur until after steady state is reached (at least 7 days). Carefully monitor adverse events such as blood pressure and kidney function during course of therapy. Alternatively, consider alternative therapy. Choose an alternative therapy not metabolized by CYP2C9 or not significantly impacted by CYP2C9 genetic variants in vivo or choose an NSAID metabolized by CYP2C9 but with a shorter half-life (Table 2).	Moderate	IMs might have a higher than normal risk of adverse events especially in individuals with other factors affecting clearance of these drugs such as hepatic impairment or advanced age. Alternative therapies not primarily metabolized by CYP2C9 include aspirin, ketorolac, naproxen and sulindac. Selection of therapy will depend on individual patient treatment goals and risks for toxicity.
CYP2C9 Poor Metabolizer	Significantly reduced metabolism and prolonged half-life; higher plasma concentrations may increase probability and/or severity of toxicities	Choose an alternative therapy not metabolized by CYP2C9 or not significantly impacted by CYP2C9 genetic variants in vivo or choose an NSAID metabolized by CYP2C9 but with a shorter half-life (Table 2).	Moderate
Indeterminate	n/a	No recommendation	No Recommendation	n/a

^*Separate drug-specific recommendation tables are available online (1).