▶UncommonHypoglycaemia.palpitations.stomatitis.
vision blurred
▶Rare or very rareNephritis tubulointerstitial.nephrotic
syndrome.renal failure.renal papillary necrosis.severe
cutaneous adverse reactions (SCARs)
▶Frequency not knownAlopecia.angioedema.aplastic
anaemia.bronchospasm.confusion.depression.
dyspnoea.embolism and thrombosis.eye irritation.eye
swelling.fertility decreased female.fluid retention.
haemolytic anaemia.haemorrhage.hallucination.heart
failure.hepatic disorders.hypersensitivity.hypertension.
malaise.mood altered.nervousness.onycholysis.
pancreatitis.paraesthesia.photosensitivity reaction.
sleep disorders.vasculitis
SIDE-EFFECTS, FURTHER INFORMATIONFor information
about cardiovascular and gastrointestinal side-effects, and
a possible exacerbation of symptoms in asthma, see Non-
steroidal anti-inflammatory drugs p. 650.
lALLERGY AND CROSS-SENSITIVITYContra-indicated in
patients with a history of hypersensitivity to aspirin or any
other NSAID—which includes those in whom attacks of
asthma, angioedema, urticaria or rhinitis have been
precipitated by aspirin or any other NSAID.
lPREGNANCYAvoid unless the potential benefit outweighs
the risk. Avoid during the third trimester (risk of closure of
fetal ductus arteriosusin uteroand possibly persistent
pulmonary hypertension of the newborn); onset of labour
may be delayed and duration may be increased.
lBREAST FEEDINGUse with caution during breast-feeding.
Amount too small to be harmful.
lHEPATIC IMPAIRMENTUse with caution; there is an
increased risk of gastro-intestinal bleeding andfluid
retention. Avoid in severe liver disease.
lRENAL IMPAIRMENTAvoid if possible or use with caution.
Dose adjustmentsThe lowest effective dose should be used
for the shortest possible duration.
MonitoringIn renal impairment monitor renal function;
sodium and water retention may occur and renal function
may deteriorate, possibly leading to renal failure.
lDIRECTIONS FOR ADMINISTRATIONPiroxicam
orodispersible tablets can be taken by placing on the
tongue and allowing to dissolve or by swallowing.
Piroxicam orodispersible tablets may be halved to give
10 mg dose.
lLESS SUITABLE FOR PRESCRIBINGPiroxicam is less
suitable for prescribing.
lMEDICINAL FORMS
There can be variation in the licensing of different medicines
containing the same drug.
Orodispersible tablet
CAUTIONARY AND ADVISORY LABELS10, 21
EXCIPIENTS:May contain Aspartame
▶Feldene Melt(Pfizer Ltd)
Piroxicam 20 mgFeldene Melt 20 mg tablets sugar-free|
30 tabletP£ 10. 53 DT = £ 10. 53
Capsule
CAUTIONARY AND ADVISORY LABELS 21
▶Piroxicam (Non-proprietary)
Piroxicam 10 mgPiroxicam 10 mg capsules| 56 capsuleP
£ 16. 82 DT = £ 4. 93
Piroxicam 20 mgPiroxicam 20 mg capsules| 28 capsuleP£ 5. 76
DT = £ 4. 51
▶Feldene(Pfizer Ltd)
Piroxicam 10 mgFeldene 10 mg capsules| 30 capsuleP£ 3. 86
Piroxicam 20 mgFeldene 20 capsules| 30 capsuleP£ 7. 71
4 Soft tissue and joint
disorders
4.1 Local inflammation of joints
and soft tissue
CORTICOSTEROIDS
Corticosteroids, inflammatory
disorders
Systemic corticosteroids
In children with rheumatic diseases corticosteroids should
be reserved for specific indications (e.g. when other
therapies are unsuccessful or while waiting for DMARDs to
take effect) and should be used only under the supervision of
a specialist.
Systemic corticosteroids may be considered for the
management of juvenile idiopathic arthritis in systemic
disease or when several joints are affected. Systemic
corticosteroids may also be considered in severe, possibly
life-threatening conditions such as systemic lupus
erythematosus, systemic vasculitis, juvenile
dermatomyositis, Behçet’s disease, and polyarticular joint
disease.
In severe conditions, short courses (‘pulses’) of high dose
intravenous methylprednisolone p. 441 or a pulsed oral
corticosteroid may be particularly effective for providing
rapid relief, and has fewer long-term adverse effects than
continuous treatment.
Corticosteroid doses should be reduced with care because
of the possibility of relapse if the reduction is too rapid. If
complete discontinuation of corticosteroids is not possible,
consideration should be given to alternate-day (or alternate
high-dose, low-dose) administration; on days when no
corticosteroid is given, or a lower dose is given, an additional
dose of a NSAID may be helpful. In some conditions,
alternative treatment using an antimalarial or concomitant
use of an immunosuppressant drug, such as azathioprine
p. 518 , methotrexate p. 543 or cyclophosphamide p. 535 may
prove useful; in less severe conditions treatment with a
NSAID alone may be adequate.
Administration of corticosteroids may result in
suppression of growth and may affect the development of
puberty. The risk of corticosteroid-induced osteoporosis
should be considered for those on long-term corticosteroid
treatment; corticosteroids may also increase the risk of
osteopenia in those unable to exercise. See the
disadvantages of corticosteroid treatment.Local corticosteroid injections
Corticosteroids are injected locally for an anti-inflammatory
effect. In inflammatory conditions of the joints, including
juvenile idiopathic arthritis, they are given byintra-articular
injectionas monotherapy, or as an adjunct to long-term
therapy to reduce swelling and deformity in one or a few
joints. Aseptic precautions (e.g. a no-touch technique) are
essential, as is a clinician skilled in the technique; infected
areas should be avoided and general anaesthesia, or local
anaesthesia, or conscious sedation should be used.
Occasionally an acute inflammatory reaction develops after
an intra-articular or soft-tissue injection of a corticosteroid.
This may be a reaction to the microcrystalline suspension of
the corticosteroid used, but must be distinguished from
sepsis introduced into the injection site.
Triamcinolone hexacetonide p. 662 [unlicensed] is
preferred for intra-articular injection because it is almost
insoluble and has a long-acting (depot) effect.BNFC 2018 – 2019 Local inflammation of joints and soft tissue 661
Musculoskeletal system10