Piroxicam (Brexin, Feldene) - Use, Dosage, Warnings, Side effects, Brands

Piroxicam (Brexin, Feldene) is a non-selective potent non-steroidal anti-inflammatory drug that has analgesic, antipyretic, and anti-inflammatory actions.

Piroxicam Uses:

  • Arthritis:

    • Relief of signs and symptoms of osteoarthritis and rheumatoid arthritis.
  • Off Label Use of Piroxicam in Adults:

    • Ankylosing spondylitis

Piroxicam dose in Adults

  • Note: Individualize dosage to lowest effective dose for the shortest duration to minimize adverse effects.

Piroxicam dose in the treatment of Osteoarthritis, and rheumatoid arthritis:

  • Oral: 20 mg once a day.

Piroxicam dose in the treatment of Ankylosing spondylitis, osteoarthritis, and rheumatoid arthritis (off-label):

  • Oral: 10 to 20 mg/day (Kroon 2015)

Piroxicam dose in Children

Piroxicam dose in the treatment of Juvenile idiopathic arthritis (JIA):

  • Children and Adolescents:

    • Oral: 0.2 to 0.4 mg/kg/day once a day;
    • The maximum daily dose: 20 mg/day (American Pain Society 2016)

Piroxicam Pregnancy Risk Category: C (D in third trimester)

  • Some studies have shown that birth defects can be caused by in utero NSAID use. However, the data is inconsistent.
  • Following in utero NSAID use, nonteratogenic effects such as prenatal constriction, persistent pulmonary hypertension, oligohydramnios and necrotizing enterocolitis have been observed in the fetus/neonate.
  • Additionally, the ductus arteriosus may not close postnatally and may not respond medically.
  • Product labeling for piroxicam clearly states that it should not be used after 30 week gestation, as NSAIDs can cause premature closing of the ductus Arteriosus.
  • NSAIDs may be used to treat mild rheumatoid-arthritis flares during pregnancy. However, it should be avoided or minimized early and often in the pregnancy.
  • Women of reproductive age who have been using NSAIDs for a long time may experience infertility. This can be reversed by stopping the medication.
  • Women who have difficulty conceiving or are undergoing fertility treatment should stop using this medication.
  • It is possible that NSAIDs taken close to conception can increase the risk of miscarriage (Bermas, 2014; Bloor 2013,).

Piroxicam use during breastfeeding:

  • Breast milk contains 1% to 3% Piroxicam.
  • NSAIDs can be used postpartum by women who want to breastfeed. However, if a woman has platelet dysfunction or thrombocytopenia, piroxicam should not be used.
  • According to the drug manufacturer breastfeeding during treatment should be considered in light of the potential for infant exposure and the benefit to the mother.

Piroxicam Dose in Kidney disease:

  • Mild to moderate impairment:

    • There are no dosage adjustments provided in the drug manufacturer’s labeling.
  • Severe impairment:

    • Use is not recommended (has not been studied); if therapy must be initiated, close monitoring is recommended.

Piroxicam Dose in Liver disease:

  • There are no specific dosage adjustments provided in the drug manufacturer’s labeling; however, a dosage reduction is recommended.

Side Effects of Piroxicam (Brexin, Feldene):

  • Cardiovascular:

    • Edema
  • Central Nervous System:

    • Dizziness
    • Headache
  • Dermatologic:

    • Pruritus
    • Skin Rash
  • Gastrointestinal:

    • Abdominal Pain
    • Anorexia
    • Constipation
    • Diarrhea
    • Dyspepsia
    • Flatulence
    • Gastrointestinal Hemorrhage
    • Gastrointestinal Perforation
    • Heartburn
    • Nausea
    • Ulcer (Gastric
    • Duodenal)
    • Vomiting
  • Hematologic & Oncologic:

    • Anemia
    • Prolonged Bleeding Time
  • Hepatic:

    • Increased Liver Enzymes
  • Otic:

    • Tinnitus
  • Renal:

    • Renal Function Abnormality

Contraindications to Piroxicam (Brexin, Feldene)):

  • Hypersensitivity/Allergy to piroxicam or to any component of the formulation;
  • Patients who have had asthma, urticaria or allergic reactions to aspirin or any other NSAIDs after they took them;
  • In the setting of coronary bypass graft surgery (CABG).

Canadian labeling: Additional contraindications not in US labeling

  • Recent or recurrent history of GI bleeding; active gastric/duodenal/peptic ulcer;
  • Active GI inflammatory Disease
  • Inflammatory bowel disease
  • cerebrovascular bleeding and other bleeding disorders
  • Grave liver impairment or active liver disease
  • Grave renal impairment (CrCl 30 mg/minute) or deteriorating kidney disease
  • Hyperkalemia is a known condition.
  • Children and adolescents under 16 years old;
  • Use in the third trimester
  • Breast-feeding
  • Uncontrolled severe heart failure

Warnings and precautions

  • Anaphylactoid reactions

    • Even in patients who have never been exposed, anaphylactoid reactions can occur.
    • Patients with the "aspirin trifecta" (bronchial asthma and aspirin intolerance, rhinitis, etc.) could be at greater risk.
    • Patients who have rhinitis or bronchospasm due to NSAID therapy or NSAID use are not advised to use.
  • Cardiovascular events: [US Boxed Warn]

    • Non-steroidal anti-inflammatory drug (NSAIDs), can increase the risk of severe (and possibly fatal) adverse cardiovascular thrombotic reactions, such as MI and stroke.
    • This risk can occur during treatment, and it may increase as the duration of treatment is continued.
    • The relative risk seems to be the same in people with and without cardiovascular disease, or risk factors for it.
    • However, patients with known cardiovascular diseases or risk factors had a higher absolute rate of cardiovascular events.
    • Exacerbation or new-onset hypertension can occur. NSAIDs could also affect the response to ACE inhibitors, thiazide or loop diuretics; may cause cardiovascular events. Monitor blood pressure.
    • Patients with edema may experience sodium and fluid retention.
    • Patients with heart disease should not use this product.
    • Patients with MI should not be used unless the benefits are greater than the risk to their cardiovascular health.
    • To reduce the risk of heart attacks, use the lowest effective dose for the most time. Patients at high risk should consider alternate treatments.
  • CNS effects

    • This may cause blurred vision, drowsiness, dizziness, blurred sight, or other neurologic effects that could impair your physical or mental capabilities. Patients should be cautious about tasks that require mental alertness such as operating machinery or driving.
    • If you have blurred or reduced vision, discontinue using the product and consult an ophthalmologist.
    • All patients undergoing long-term therapy should be evaluated periodically for vision.
  • [US Boxed Warning]: GI events

    • NSAIDs can increase the risk of serious GI side effect such as GI inflammation and bleeding that could be fatal.
    • Patients with a history of PUD or GI bleeding and elderly patients are more at risk.
    • These events can occur without warning and may happen at any stage of therapy.
    • Patients with active GI bleeding should not be used.
    • Avoid non-aspirin NSAIDs in patients who have had a history or recent experience with acute lower GI bleeding.
    • This is especially important if the bleeding occurs due to angioectasia, diverticulosis, or other causes.
    • Patients with a history of GI bleeding, concordant therapy that can exaggerate the risk (eg, aspirin and anticoagulants, SSRIs), smoking or elderly patients should be cautious.
    • To minimize the risk of GI adverse reactions, use the lowest effective dose for the shortest time. Patients at high risk should consider other treatments.
    • When used adjacently with aspirin, a substantial exacerbation in the risk of GI complications (eg, ulcer) occurs; adjacent gastroprotective therapy (eg, proton pump inhibitors) is recommended.
  • Hematologic effects

    • Patients with coagulation disorders and those on anticoagulants need to be closely monitored for platelet adhesion or aggregation.
    • Anemia can occur. Patients on long-term NSAID therapy need to be closely monitored.
    • Rarely, NSAIDs have been associated with severe blood dyscrasias, such as thrombocytopenia, agranulocytosis and aplastic anemia.
  • Hyperkalemia:

    • NSAIDs may increase the risk of hyperkalemia in older people, diabetics, those with renal disease and those who use other agents that can cause hyperkalemia (e.g. ACE-inhibitors).
    • Monitor potassium closely.
  • Ovulation

    • Reversible infertility may occur if the ovarian follicles are not ruptured. Some studies also show a delay or reversible decrease in ovulation.
    • Women who have difficulties conceiving or are infertile should consider discontinuing treatment.
  • Serum sickness:

    • Rarely, a serum sickness-like reaction may occur. Be aware of joint pains, fever, fatigue, and other symptoms.
  • Reactions to skin:

    • NSAIDs can cause severe skin adverse reactions, including Stevens-Johnson syndrome (SJS), toxic epidermal necrolysis and exfoliative dermatitis (TEN).
    • Stop using the medication immediately if you develop skin rash or hypersensitivity.
  • Asthma

    • Patients with asthma that is aspirin-sensitive should not be given medication; severe bronchospasm can occur.
    • Patients with other forms or asthma should be cautious.
  • Bariatric surgery

    • Gastric ulceration: After bariatric surgery, avoid the use of non-selective oral NSAIDs for long periods.
    • The development of anastomotic ulcerations/perforations may occur.
    • Short-term use of celecoxib or IV ketorolac is recommended as part of a multimodal pain management strategy for postoperative pain.
  • Coronary bypass surgery for coronary artery bypass: [US Boxed Warn]

    • In the case of coronary bypass graft (CABG), surgery, it is not recommended to use.
    • After CABG surgery, stroke and MI risk may increase.
  • Hepatic impairment

    • Patients with reduced hepatic function should be cautious.
    • Monitor patients with abnormal LFT closely.
    • Rare, sometimes fatal, severe hepatic reactions have been reported with NSAIDs.
    • If you experience liver disease symptoms, persistent or worsening abnormal hepatic function testing, discontinue use.
  • Hypertension:

    • Be careful, as you may increase your risk of developing hypertension.
    • At initiation and throughout piroxicam therapy, monitor your blood pressure.
  • Renal impairment

    • NSAIDs can cause impairment of renal function. Dose-dependent decreases may occur in prostaglandin synthesis due to NSAID use.
    • This could lead to reduced renal blood flow, which may lead to renal decompensation.
    • Patients with impaired renal function, hypovolemia and heart failure, as well as those who take diuretics and ACE inhibitors and angiotensin II receptor blocking drugs, are more at risk for renal toxicity.
    • Before starting treatment, hydrate the patient and monitor your renal function.
    • Patients with advanced renal disease should not use this medication. If you have persistent or worsening abnormal kidney function tests, discontinue use.
    • Long-term NSAID treatment may cause renal papillary necrosis.

Piroxicam: Drug Interaction

Risk Factor C (Monitor therapy)

5-Aminosalicylic Acid Derivatives

Nonsteroidal Anti-Inflammatory Agents may enhance the nephrotoxic effect of 5-Aminosalicylic Acid Derivatives.

Agents with Antiplatelet Properties (e.g., P2Y12 inhibitors, NSAIDs, SSRIs, etc.)

May enhance the antiplatelet effect of other Agents with Antiplatelet Properties.

Alcohol (Ethyl)

May enhance the adverse/toxic effect of Nonsteroidal Anti-Inflammatory Agents. Specifically, the risk of GI bleeding may be increased with this combination.

Aliskiren

Nonsteroidal Anti-Inflammatory Agents may diminish the antihypertensive effect of Aliskiren. Nonsteroidal Anti-Inflammatory Agents may enhance the nephrotoxic effect of Aliskiren. Management: Monitor renal function periodically in patients receiving aliskiren and any nonsteroidal anti-inflammatory agent. Patients at elevated risk of renal dysfunction include those who are elderly, are volume depleted, or have pre-existing renal dysfunction.

Alpelisib

May decrease the serum concentration of CYP2C9 Substrates (High risk with Inducers).

Aminoglycosides

Nonsteroidal Anti-Inflammatory Agents may decrease the excretion of Aminoglycosides. Data only in premature infants.

Aminolevulinic Acid (Topical)

Photosensitizing Agents may enhance the photosensitizing effect of Aminolevulinic Acid (Topical).

Angiotensin II Receptor Blockers

May enhance the adverse/toxic effect of Nonsteroidal AntiInflammatory Agents. Specifically, the combination may result in a significant decrease in renal function. Nonsteroidal Anti-Inflammatory Agents may diminish the therapeutic effect of Angiotensin II Receptor Blockers. The combination of these two agents may also significantly decrease glomerular filtration and renal function.

Angiotensin-Converting Enzyme Inhibitors

May enhance the adverse/toxic effect of Nonsteroidal Anti-Inflammatory Agents. Specifically, the combination may result in a significant decrease in renal function. Nonsteroidal Anti-Inflammatory Agents may diminish the antihypertensive effect of Angiotensin-Converting Enzyme Inhibitors.

Anticoagulants

Agents with Antiplatelet Properties may enhance the anticoagulant effect of Anticoagulants. Exceptions: Bemiparin; Enoxaparin; Heparin.

Anticoagulants

Nonsteroidal Anti-Inflammatory Agents may enhance the anticoagulant effect of Anticoagulants. Exceptions: Bemiparin; Enoxaparin; Heparin.

Beta-Blockers

Nonsteroidal Anti-Inflammatory Agents may diminish the antihypertensive effect of Beta-Blockers. Exceptions: Levobunolol; Metipranolol.

Bisphosphonate Derivatives

Nonsteroidal Anti-Inflammatory Agents may enhance the adverse/toxic effect of Bisphosphonate Derivatives. Both an increased risk of gastrointestinal ulceration and an increased risk of nephrotoxicity are of concern.

Cephalothin

Agents with Antiplatelet Properties may enhance the adverse/toxic effect of Cephalothin. Specifically, the risk for bleeding may be increased.

Collagenase (Systemic)

Agents with Antiplatelet Properties may enhance the adverse/toxic effect of Collagenase (Systemic). Specifically, the risk of injection site bruising and/or bleeding may be increased.

Corticosteroids (Systemic)

May enhance the adverse/toxic effect of Nonsteroidal AntiInflammatory Agents (Nonselective).

CYP2C9 Inducers (Moderate)

May decrease the serum concentration of CYP2C9 Substrates (High risk with Inducers).

CYP2C9 Inhibitors (Moderate

May decrease the metabolism of CYP2C9 Substrates (High risk with Inhibitors).

Dasatinib

May enhance the anticoagulant effect of Agents with Antiplatelet Properties. Management: Drugs listed as exceptions to this monograph are discussed in further detail in separate drug interaction monographs.

Deferasirox

Nonsteroidal Anti-Inflammatory Agents may enhance the adverse/toxic effect of Deferasirox. Specifically, the risk for GI ulceration/irritation or GI bleeding may be increased.

Deoxycholic Acid

Agents with Antiplatelet Properties may enhance the adverse/toxic effect of Deoxycholic Acid. Specifically, the risk for bleeding or bruising in the treatment area may be increased.

Desmopressin

Nonsteroidal Anti-Inflammatory Agents may enhance the adverse/toxic effect of Desmopressin.

Digoxin

Nonsteroidal Anti-Inflammatory Agents may increase the serum concentration of Digoxin.

Drospirenone

Nonsteroidal Anti-Inflammatory Agents may enhance the hyperkalemic effect of Drospirenone.

Eplerenone

Nonsteroidal Anti-Inflammatory Agents may diminish the antihypertensive effect of Eplerenone. Nonsteroidal Anti-Inflammatory Agents may enhance the hyperkalemic effect of Eplerenone.

Fat Emulsion (Fish Oil Based)

May enhance the adverse/toxic effect of Agents with Antiplatelet Properties.

Felbinac

May enhance the adverse/toxic effect of Nonsteroidal Anti-Inflammatory Agents.

Glucosamine

May enhance the antiplatelet effect of Agents with Antiplatelet Properties.

Haloperidol

Nonsteroidal Anti-Inflammatory Agents may enhance the adverse/toxic effect of Haloperidol. Specifically including drowsiness and confusion.

HydrALAZINE

Nonsteroidal Anti-Inflammatory Agents may diminish the antihypertensive effect of HydrALAZINE.

Ibritumomab Tiuxetan

Agents with Antiplatelet Properties may enhance the adverse/toxic effect of Ibritumomab Tiuxetan. Both agents may contribute to impaired platelet function and an increased risk of bleeding.

Ibrutinib

May enhance the adverse/toxic effect of Agents with Antiplatelet Properties.

Inotersen

May enhance the antiplatelet effect of Agents with Antiplatelet Properties.

Limaprost

May enhance the antiplatelet effect of Agents with Antiplatelet Properties.

Lumacaftor

May decrease the serum concentration of CYP2C9 Substrates (High Risk with Inhibitors or Inducers). Lumacaftor may increase the serum concentration of CYP2C9 Substrates (High Risk with Inhibitors or Inducers).

Multivitamins/Fluoride (with ADE)

May enhance the antiplatelet effect of Agents with Antiplatelet Properties.

Multivitamins/Minerals (with ADEK, Folate, Iron)

May enhance the antiplatelet effect of Agents with Antiplatelet Properties.

Multivitamins/Minerals (with AE, No Iron)

May enhance the antiplatelet effect of Agents with Antiplatelet Properties.

Naftazone

May enhance the antiplatelet effect of Nonsteroidal Anti-Inflammatory Agents.

Obinutuzumab

Agents with Antiplatelet Properties may enhance the adverse/toxic effect of Obinutuzumab. Specifically, the risk of serious bleeding-related events may be increased.

Omega-3 Fatty Acids

May enhance the antiplatelet effect of Agents with Antiplatelet Properties.

Pentosan Polysulfate Sodium

May enhance the adverse/toxic effect of Agents with Antiplatelet Properties. Specifically, the risk of bleeding may be increased by concurrent use of these agents.

Pentoxifylline

May enhance the antiplatelet effect of Agents with Antiplatelet Properties.

Porfimer

Photosensitizing Agents may enhance the photosensitizing effect of Porfimer.

Potassium-Sparing Diuretics

Nonsteroidal Anti-Inflammatory Agents may diminish the antihypertensive effect of Potassium-Sparing Diuretics. Nonsteroidal Anti-Inflammatory Agents may enhance the hyperkalemic effect of Potassium-Sparing Diuretics.

PRALAtrexate

Nonsteroidal Anti-Inflammatory Agents may increase the serum concentration of PRALAtrexate. More specifically, NSAIDS may decrease the renal excretion of pralatrexate. Management: Closely monitor for increased pralatrexate serum levels and/or toxicity if used concomitantly with an NSAID. Monitor for decreased pralatrexate serum levels with NSAID discontinuation.

Probenecid

May increase the serum concentration of Nonsteroidal Anti-Inflammatory Agents.

Prostacyclin Analogues

May enhance the antiplatelet effect of Agents with Antiplatelet Properties.

Prostaglandins (Ophthalmic)

Nonsteroidal Anti-Inflammatory Agents may diminish the therapeutic effect of Prostaglandins (Ophthalmic). Nonsteroidal Anti-Inflammatory Agents may also enhance the therapeutic effects of Prostaglandins (Ophthalmic).

Quinolones

Nonsteroidal Anti-Inflammatory Agents may enhance the neuroexcitatory and/or seizure-potentiating effect of Quinolones. Nonsteroidal Anti-Inflammatory Agents may increase the serum concentration of Quinolones.

Rifapentine

May decrease the serum concentration of CYP2C9 Substrates (High risk with Inducers).

Salicylates

Agents with Antiplatelet Properties may enhance the adverse/toxic effect of Salicylates. Increased risk of bleeding may result.

Serotonin/Norepinephrine Reuptake Inhibitors

May enhance the antiplatelet effect of Nonsteroidal Anti-Inflammatory Agents (Nonselective).

Tacrolimus (Systemic)

Nonsteroidal Anti-Inflammatory Agents may enhance the nephrotoxic effect of Tacrolimus (Systemic).

Thiazide and Thiazide-Like Diuretics

May enhance the nephrotoxic effect of Nonsteroidal AntiInflammatory Agents. Nonsteroidal Anti-Inflammatory Agents may diminish the therapeutic effect of Thiazide and Thiazide-Like Diuretics.

Thrombolytic Agents

Agents with Antiplatelet Properties may enhance the anticoagulant effect of Thrombolytic Agents.

Tipranavir

May enhance the antiplatelet effect of Agents with Antiplatelet Properties.

Tolperisone

Nonsteroidal Anti-Inflammatory Agents may enhance the adverse/toxic effect of Tolperisone. Specifically, the risk of hypersensitivity reactions may be increased. Tolperisone may enhance the therapeutic effect of Nonsteroidal Anti-Inflammatory Agents.

Tricyclic Antidepressants (Tertiary Amine)

May enhance the antiplatelet effect of Nonsteroidal Anti-Inflammatory Agents (Nonselective).

Vancomycin

Nonsteroidal Anti-Inflammatory Agents may increase the serum concentration of Vancomycin.

Verteporfin

Photosensitizing Agents may enhance the photosensitizing effect of Verteporfin.

Vitamin E (Systemic)

May enhance the antiplatelet effect of Agents with Antiplatelet Properties.

Risk Factor D (Consider therapy modification)

Apixaban

Nonsteroidal Anti-Inflammatory Agents (Nonselective) may enhance the adverse/toxic effect of Apixaban. Specifically, the risk of bleeding may be increased. Management: A comprehensive risk to benefit assessment should be done for all patients before any concurrent use of apixaban and nonsteroidal anti-inflammatory drugs (NSAIDs). If combined, monitor patients extra closely for signs and symptoms of bleeding.

Bemiparin

Nonsteroidal Anti-Inflammatory Agents may enhance the anticoagulant effect of Bemiparin. Management: Avoid concomitant use of bemiparin and nonsteroidal anti-inflammatory agents (NSAIDs) due to the increased risk of bleeding. If concomitant use is unavoidable, monitor closely for signs and symptoms of bleeding.

Bemiparin

Agents with Antiplatelet Properties may enhance the anticoagulant effect of Bemiparin. Management: Avoid concomitant use of bemiparin with antiplatelet agents. If concomitant use is unavoidable, monitor closely for signs and symptoms of bleeding.

Bile Acid Sequestrants

May decrease the absorption of Nonsteroidal Anti-Inflammatory Agents.

CycloSPORINE (Systemic)

Nonsteroidal Anti-Inflammatory Agents may enhance the nephrotoxic effect of CycloSPORINE (Systemic). Nonsteroidal Anti-Inflammatory Agents may increase the serum concentration of CycloSPORINE (Systemic). CycloSPORINE (Systemic) may increase the serum concentration of Nonsteroidal Anti-Inflammatory Agents. Management: Consider alternatives to nonsteroidal anti-inflammatory agents (NSAIDs). Monitor for evidence of nephrotoxicity, as well as increased serum cyclosporine concentrations and systemic effects (eg, hypertension) during concomitant therapy with NSAIDs.

Dabigatran Etexilate

Nonsteroidal Anti-Inflammatory Agents (Nonselective) may enhance the adverse/toxic effect of Dabigatran Etexilate. Specifically, the risk of bleeding may be increased. Management: A comprehensive risk to benefit assessment should be done for all patients before any concurrent use of dabigatran and nonsteroidal anti-inflammatory drugs (NSAIDs). If combined, monitor patients extra closely for signs and symptoms of bleeding.

Dabrafenib

May decrease the serum concentration of CYP2C9 Substrates (High risk with Inducers). Management: Seek alternatives to the CYP2C9 substrate when possible. If concomitant therapy cannot be avoided, monitor clinical effects of the substrate closely (particularly therapeutic effects).

Diclofenac (Systemic

May enhance the adverse/toxic effect of Nonsteroidal Anti-Inflammatory Agents. Management: Seek alternatives to the combined use of diclofenac with other nonsteroidal anti-inflammatory agents (NSAIDs). Avoid the use of diclofenac/misoprostol with other NSAIDs.

Edoxaban

Nonsteroidal Anti-Inflammatory Agents (Nonselective) may enhance the adverse/toxic effect of Edoxaban. Specifically, the risk of bleeding may be increased. Management: A comprehensive risk to benefit assessment should be done for all patients before any concurrent use of edoxaban and nonsteroidal anti-inflammatory drugs (NSAIDs). If combined, monitor patients extra closely for signs and symptoms of bleeding.

Enoxaparin

Nonsteroidal Anti-Inflammatory Agents may enhance the anticoagulant effect of Enoxaparin. Management: Discontinue nonsteroidal anti-inflammatory agents (NSAIDs) prior to initiating enoxaparin whenever possible. If concomitant administration is unavoidable, monitor closely for signs and symptoms of bleeding.

Enoxaparin

Agents with Antiplatelet Properties may enhance the anticoagulant effect of Enoxaparin. Management: Discontinue antiplatelet agents prior to initiating enoxaparin whenever possible. If concomitant administration is unavoidable, monitor closely for signs and symptoms of bleeding.

Enzalutamide

May decrease the serum concentration of CYP2C9 Substrates (High risk with Inducers). Management: Concurrent use of enzalutamide with CYP2C9 substrates that have a narrow therapeutic index should be avoided. Use of enzalutamide and any other CYP2C9 substrate should be performed with caution and close monitoring.

Heparin

Nonsteroidal Anti-Inflammatory Agents may enhance the anticoagulant effect of Heparin. Management: Decrease the dose of heparin or nonsteroidal anti-inflammatory agents (NSAIDs) if coadministration is required.

Heparin

Agents with Antiplatelet Properties may enhance the anticoagulant effect of Heparin. Management: Decrease the dose of heparin or agents with antiplatelet properties if coadministration is required.

Herbs (Anticoagulant/Antiplatelet Properties) (eg, Alfalfa, Anise, Bilberry)

May enhance the adverse/toxic effect of Agents with Antiplatelet Properties. Bleeding may occur. Management: Avoid combination when possible. If used, monitor more closely for evidence of bleeding. Discontinue herbal products with anticoagulant or antiplatelet actions 2 weeks prior to surgical, dental, or invasive procedures.

Herbs (Anticoagulant/Antiplatelet Properties) (eg, Alfalfa, Anise, Bilberry)

May enhance the adverse/toxic effect of Nonsteroidal Anti-Inflammatory Agents. Bleeding may occur. Management: Concomitant treatment with these agents should generally be avoided. If used concomitantly, increased diligence in monitoring for adverse effects (eg, bleeding, bruising, altered mental status due to CNS bleeds) must be employed.

Lithium

Nonsteroidal Anti-Inflammatory Agents may increase the serum concentration of Lithium.

Loop Diuretics

Nonsteroidal Anti-Inflammatory Agents may diminish the diuretic effect of Loop Diuretics. Loop Diuretics may enhance the nephrotoxic effect of Nonsteroidal Anti-Inflammatory Agents. Management: Monitor for evidence of kidney injury or decreased therapeutic effects of loop diuretics with concurrent use of an NSAID. Consider avoiding concurrent use in CHF or cirrhosis. Concomitant use of bumetanide with indomethacin is not recommended.

Methotrexate

Nonsteroidal Anti-Inflammatory Agents may increase the serum concentration of Methotrexate. Management: Alternative anti-inflammatory therapy should be considered whenever possible, especially if the patient is receiving higher, antineoplastic doses of methotrexate.

MiFEPRIStone

May increase the serum concentration of CYP2C9 Substrates (High risk with Inhibitors). Management: Use CYP2C9 substrates at the lowest recommended dose, and monitor closely for adverse effects, during and in the 2 weeks following mifepristone treatment.

Rivaroxaban

Nonsteroidal Anti-Inflammatory Agents (Nonselective) may enhance the adverse/toxic effect of Rivaroxaban. Specifically, the risk of bleeding may be increased. Management: A comprehensive risk to benefit assessment should be done for all patients before any concurrent use of rivaroxaban and nonsteroidal anti-inflammatory drugs (NSAIDs). If combined, monitor patients extra closely for signs and symptoms of bleeding.

Salicylates

Nonsteroidal Anti-Inflammatory Agents (Nonselective) may enhance the adverse/toxic effect of Salicylates. An increased risk of bleeding may be associated with use of this combination. Nonsteroidal Anti-Inflammatory Agents (Nonselective) may diminish the cardioprotective effect of Salicylates. Salicylates may decrease the serum concentration of Nonsteroidal Anti-Inflammatory Agents (Nonselective). Exceptions: Choline Magnesium Trisalicylate.

Selective Serotonin Reuptake Inhibitors

May enhance the antiplatelet effect of Nonsteroidal AntiInflammatory Agents (Nonselective). Nonsteroidal Anti-Inflammatory Agents (Nonselective) may diminish the therapeutic effect of Selective Serotonin Reuptake Inhibitors. Management: Consider alternatives to NSAIDs. Monitor for evidence of bleeding and diminished antidepressant effects. It is unclear whether COX-2-selective NSAIDs reduce risk.

Sincalide

Drugs that Affect Gallbladder Function may diminish the therapeutic effect of Sincalide. Management: Consider discontinuing drugs that may affect gallbladder motility prior to the use of sincalide to stimulate gallbladder contraction.

Sodium Phosphates

May enhance the nephrotoxic effect of Nonsteroidal Anti-Inflammatory Agents. Specifically, the risk of acute phosphate nephropathy may be enhanced. Management: Consider avoiding this combination by temporarily suspending treatment with NSAIDs, or seeking alternatives to oral sodium phosphate bowel preparation. If the combination cannot be avoided, maintain adequate hydration and monitor renal function closely.

Tenofovir Products

Nonsteroidal Anti-Inflammatory Agents may enhance the nephrotoxic effect of Tenofovir Products. Management: Seek alternatives to these combinations whenever possible. Avoid use of tenofovir with multiple NSAIDs or any NSAID given at a high dose.

Vitamin K Antagonists (eg, warfarin)

Nonsteroidal Anti-Inflammatory Agents (Nonselective) may enhance the anticoagulant effect of Vitamin K Antagonists.

Risk Factor X (Avoid combination)

Acemetacin

May enhance the adverse/toxic effect of Nonsteroidal Anti-Inflammatory Agents.

Aminolevulinic Acid (Systemic)

Photosensitizing Agents may enhance the photosensitizing effect of Aminolevulinic Acid (Systemic).

Dexibuprofen

Nonsteroidal Anti-Inflammatory Agents may enhance the adverse/toxic effect of Dexibuprofen.

Dexketoprofen

May enhance the adverse/toxic effect of Nonsteroidal Anti-Inflammatory Agents.

Floctafenine

May enhance the adverse/toxic effect of Nonsteroidal Anti-Inflammatory Agents.

Ketorolac (Nasal)

May enhance the adverse/toxic effect of Nonsteroidal Anti-Inflammatory Agents.

Ketorolac (Systemic

May enhance the adverse/toxic effect of Nonsteroidal Anti-Inflammatory Agents.

Macimorelin

Nonsteroidal Anti-Inflammatory Agents may diminish the diagnostic effect of Macimorelin.

Mifamurtide

Nonsteroidal Anti-Inflammatory Agents may diminish the therapeutic effect of Mifamurtide.

Morniflumate

May enhance the adverse/toxic effect of Nonsteroidal Anti-Inflammatory Agents.

Nonsteroidal Anti-Inflammatory Agents (COX-2 Selective)

Nonsteroidal Anti-Inflammatory Agents may enhance the adverse/toxic effect of Nonsteroidal Anti-Inflammatory Agents (COX-2 Selective).

Omacetaxine

Nonsteroidal Anti-Inflammatory Agents may enhance the adverse/toxic effect of Omacetaxine. Specifically, the risk for bleeding-related events may be increased. Management: Avoid concurrent use of nonsteroidal antiinflammatory drugs (NSAIDs) with omacetaxine in patients with a platelet count of less than 50,000/uL.

Pelubiprofen

May enhance the adverse/toxic effect of Nonsteroidal Anti-Inflammatory Agents.

Phenylbutazone

May enhance the adverse/toxic effect of Nonsteroidal Anti-Inflammatory Agents.

Talniflumate

May enhance the adverse/toxic effect of Nonsteroidal Anti-Inflammatory Agents.

Tenoxicam

May enhance the adverse/toxic effect of Nonsteroidal Anti-Inflammatory Agents.

Urokinase

Agents with Antiplatelet Properties may enhance the anticoagulant effect of Urokinase.

Zaltoprofen

May enhance the adverse/toxic effect of Nonsteroidal Anti-Inflammatory Agents.

Monitoring parameters:

  • Occult blood loss,
  • hemoglobin,
  • hematocrit,
  • electrolytes,
  • and periodic renal and hepatic function tests;
  • periodic ophthalmologic exams with chronic use

How to administer Piroxicam (Feldene, Brexin)?

  • Oral: May administer in a single daily dose or divide twice a day.
  • It can be administered with food or milk to reduce GI side effects.

Mechanism of action of Piroxicam (Feldene, Brexin):

  • Reversible inhibition of COX-1 and COX-2 enzymes which causes less formation protaglandin precursors.
  • Other proposed mechanisms not fully explained (and possibly contributing to the anti-inflammatory effect to varying degrees), include inhibiting chemotaxis, altering the activity of lymphocyte, inhibiting neutrophil aggregation/activation, and decreasing proinflammatory cytokine levels.

The onset of action:

  • Analgesia: Oral: Within 1 hour;
  • Maximum effect: 3 to 5 hours

Absorption:

  • Oral: Well absorbed

Protein binding:

  • 99%

Metabolism:

  • Hepatic predominantly via CYP2C9; metabolites are inactive

Half-life elimination:

  • Children and Adolescents 7 to 16 years: 32.6 hours; Range: 22 to 40 hours.
  • Adults: 50 hours

Time to peak:

  • 3 to 5 hours

Excretion:

  • Primarily urine and feces (small amounts) as unchanged drug (5%) and metabolites

International Brands of Piroxicam:

  • Feldene
  • APO-Piroxicam
  • DOM-Piroxicam
  • PMS-Piroxicam
  • TEVA-Piroxicam
  • Ameroxicam
  • Anflene
  • Anmatic
  • Antiflog
  • Arotika Cool
  • Artronil
  • Atidem
  • Baxo
  • Benisan
  • Brexic
  • Brexidol
  • Brexin
  • Brexine
  • Brucam
  • Bruxicam
  • Butacinon
  • Campain
  • Candyl-D
  • Citoken T
  • Dispercam
  • Dolonex
  • Edecam
  • Erazon
  • Exipan
  • Facicam
  • Felcam
  • Feldegel
  • Felden
  • Felden Gel
  • Feldene
  • Feldene Gel
  • Feldoral
  • Fines
  • Flamexin
  • Flamic Gel
  • Flexar
  • Flexicam
  • Flodol Gel
  • Focus
  • Gelprox
  • Genoldene
  • Hotemin
  • Improntal
  • Infeld
  • Inflamene
  • Kapirox
  • Konshien
  • Kydoflam
  • Leal
  • Lubor
  • Macroxam
  • Maxidene
  • Mobilis
  • Mobilus
  • Movon Gel
  • Movon-20
  • Murupe Patch 48
  • Nac
  • Nysa
  • PC-20
  • Pemar
  • Pillozen
  • Pirac
  • Piram
  • Piram-D
  • Pirax
  • Pirocam
  • Pirocutan
  • Pirocutan Gel
  • Pirogel
  • Pirom
  • Piromed
  • Pirosol
  • Pirox
  • Pirox IM
  • Piroxam
  • Piroxedol
  • Piroxene
  • Piroxicam
  • Piroxim
  • Piroxin
  • Pixicam
  • Pleroxi
  • Proxalyoc
  • Proximax
  • Pyridam
  • Pyrolox
  • Pyroxy
  • Rheo-Ma Inj
  • Rheudene
  • Rheugesic
  • Rosiden
  • Roxicam
  • Roxican
  • Roxifen
  • Roxitan
  • Roxium
  • Ruvamed
  • Salvacam
  • Sefdene
  • Sinalgico
  • Solocalm
  • Sotilen
  • Stopen
  • Toricam Gel
  • Tropidene
  • Unicam
  • Vendocid
  • Xicalom
  • Xicam
  • Xycam
  • Zincun
  • Zitumex
  • Zofora
  • Zuparex

Piroxicam Brand Names in Pakistan:

Piroxicam Injection 20 mg/ml

Aksocam Akson Pharmaceuticals (Pvt) Ltd.
Betadex Ray Pharma (Pvt) Ltd
Bropox Wellborne Pharmachem And Biologicals
Camitle Myrtle Pharma Kar.
Epharox Epharm Laboratories
Fasicamx Fassgen Pharmaceuticals
Frogen Zinta Pharmaceuticals Industries
Heldene Hygeia Pharmaceuticals
Mobicam Global Pharmaceuticals
Modivid Caraway Pharmaceuticals
Muvon Neutro Pharma (Pvt) Ltd.
Nicep Medisave Pharmaceuticals
Oxicam Ipram International
Pcam Merck Private Ltd.
Piroflam Polyfine Chempharma (Pvt) Ltd.
Pirowan Swan Pharmaceuticals(Pvt) Ltd
Piroxilite Elite Pharma
Pulsecam Pulse Pharmaceuticals
Rheupain Mediate Pharmaceuticals (Pvt) Ltd
Rosiden Medisure Laboratories Pakistan (Pvt.) Ltd.
Rumolon Inj Tabros Pharma
Weldene Wilshire Laboratories (Pvt) Ltd.
Xycam Mediceena Pharma (Pvt) Ltd.
Zicam Goodman Laboratories

 

Piroxicam Injection-IM 20 mg/ml

Feldene Pfizer Laboratories Ltd.

 

Piroxicam Syrup 2 mg/5ml

Broven Chas. A. Mendoza

 

Piroxicam  Cream 1 % W/W 

Riacen Lahore Chemical & Pharmaceutical Works (Pvt) Ltd

 

Piroxicam Cream 0.5 % W/W 

Riacen Chiesi Pharmaceuticals (Pvt) Ltd.

 

Piroxicam Gel 0.5 % W/W

Alicam Webros Pharmaceuticals
Camgen Biogen Pharma
Comatic Neutro Pharma (Pvt) Ltd.
Diodex Pearl Pharmaceuticals
Ericam Zephyr Pharmatec (Pvt) Ltd.
Feldene Pfizer Laboratories Ltd.
Fenoxim Medisearch Pharmacal(Pvt) Ltd
Hyalgan Gel Nimrall Laboratories
Mobicam Global Pharmaceuticals
Mod Caraway Pharmaceuticals
Modivid Caraway Pharmaceuticals
Orthosap Sapient Pharma
Oxipro Shrooq Pharmaceuticals
Pcam Merck Private Ltd.
Pharox Valor Pharmaceuticals
Piram Navegal Laboratories
Poxicam Bio Labs (Pvt) Ltd.
Proxim Novartis Pharma (Pak) Ltd
Rheupain Mediate Pharmaceuticals (Pvt) Ltd
Rosiden Medisure Laboratories Pakistan (Pvt.) Ltd.
Rosiden Medisure Laboratories Pakistan (Pvt.) Ltd.
Roxicam Wilsons Pharmaceuticals
Roxim Spl Pharmaceuticals (Pvt) Ltd
Sonicam Syntex Pharmaceuticals
Xorip Reliance Pharma
Zecam Zeb Laboratories

 

Piroxicam 2 mg Tablets

Broven Chas. A. Mendoza

 

Piroxicam 10 mg Tablets

Abxicam Innvotek Pharmaceuticals
Allicam Webros Pharmaceuticals
Anarom Caylex Pharmaceuticals (Pvt) Ltd.
Davirox Davis Pharmaceutical Laboratories
Discam Davis Pharmaceutical Laboratories
Exican B Nova Med Pharmaceuticals
Feldene Pfizer Laboratories Ltd.
Feldicam Rex Pharmaceuticals Pakistan
Limbar Siza International (Pvt) Ltd.
O-Zole Nova Med Pharmaceuticals
Oram Bryon Pharmaceuticals (Pvt) Ltd.
Osteocam Mega Pharmaceuticals (Pvt) Ltd
Pcam Merck Private Ltd.
Pharox Valor Pharmaceuticals
Rheucam Epoch Pharmaceutical
Rheucam Epoch Pharmaceutical

 

Piroxicam 20 mg Tablets

Abxicam Innvotek Pharmaceuticals
Allicam Webros Pharmaceuticals
Anarom Caylex Pharmaceuticals (Pvt) Ltd.
Arcam Saydon Pharmaceutical Industries (Pvt) Ltd.
Bcd-20 Gillman Pharmaceuticals
Beka Glitz Pharma
Beladex Sapient Pharma
Betamark Welmark Pharmaceuticals
Betane Genera Pharmaceuticals
Biodextrin Biorex Pharmaceuticals
Bless Medizan Labs (Pvt) Ltd
Brysk Dyson Research Laboratories
Cam Hisun Pharmaceuticals
Camgen Biogen Pharma
Cirer Nawan Laboratories (Pvt) Ltd.
Comfam Pulse Pharmaceuticals
Cyclobex Roryan Pharmaceutical Industries (Pvt) Ltd
Cyclocam Plus Crest Pharmaceuticals
Cyclodex Platinum Pharmaceuticals (Pvt.) Ltd.
Cyclodor Shaheen Agencies
Cydex Alfalah Pharma (Pvt) Ltd.
Dexin Qintar Pharmacuticals
Diodex Pearl Pharmaceuticals
Discam Davis Pharmaceutical Laboratories
Epharox Epharm Laboratories
Ever-Pir Everest Pharmaceuticals
Exican Nova Med Pharmaceuticals
Fai-Cam Unison Chemical Works
Feldene Pfizer Laboratories Ltd.
Feldene Ffd Pfizer Laboratories Ltd.
Feldicam Rex Pharmaceuticals Pakistan
Hocam Honig Pharmaceuticals Laboratories
Limbar Siza International (Pvt) Ltd.
Locam Paramount Pharmaceuticals
Mcdex English Pharmaceuticals Industries
Mquin Macquins International
Mrexin Medifine Laboratories
Nagid Csh Pharmaceuticals-North (Pvt) Ltd
Naldene Pharmawise Labs. (Pvt) Ltd.
Novagesic Envoy Pharma
O-Zole Nova Med Pharmaceuticals
Oram Bryon Pharmaceuticals (Pvt) Ltd.
Orthosap Sapient Pharma
Orthram Davis Pharmaceutical Laboratories
Osteocam Mega Pharmaceuticals (Pvt) Ltd
Oxibet Silver Oak Corporation.
Oxicam Ipram International
Oxipro Shrooq Pharmaceuticals
Paladon Venture Chemical & Pharmaceuticals (Pvt) Ltd.
Pancare Regent Laboratories Ltd.
Parqin Qintar Pharmacuticals
Paxam Dr. Raza Pharma (Private) Limited
Paxil 20 Shaigan Pharmaceuticals (Pvt) Ltd
Paxyl Harmann Pharmaceutical Laboratories (Pvt) Ltd.
Payaram Medicraft Pharmaceuticals (Pvt) Ltd.
Payram Medicraft Pharmaceuticals (Pvt) Ltd.
Pcam Merck Private Ltd.
Peerox-B Goodman Laboratories
Perdin Genome Pharmaceuticals (Pvt) Ltd
Pericam Don Valley Pharmaceuticals (Pvt) Ltd.
Pharox-B Valor Pharmaceuticals
Piraxin Tabros Pharma
Piricam Lowitt Pharmaceuticals (Pvt) Ltd
Piro-D Pakheim Internanational Pharma
Pirodex Schazoo Zaka
Pirolive Olive Pharmaceuticals
Pirosil Cirin Pharmaceuticals (Pvt) Ltd.
Pirotek W & Ali Sons Pharmaceuticals
Pirotel Ideal Pharmaceutical Industries
Pirotel Ideal Pharmaceutical Industries
Piroxibet Lawari International
Piroxibron Wellborne Pharmachem And Biologicals
Piroxirown-B Crown Pharmaceuticals
Preksin Universal Pharmaceuticals (Pvt) Ltd
Proxilib Stalwart Pharmaceuticals (Pvt) Ltd
Proxim Novartis Pharma (Pak) Ltd
Pyroxi Lotus Pharmaceuticals (Pvt) Ltd
Qitar Ambrosia Pharmaceuticals
Qluz Wilshire Laboratories (Pvt) Ltd.
Rheucam Epoch Pharmaceutical
Rheucam Epoch Pharmaceutical
Rheumonil Batala Pharmaceuticals.
Ripocam Syntex Pharmaceuticals
Rocicain Aries Pharmaceuticals (Pvt) Ltd
Rocicain Aries Pharmaceuticals (Pvt) Ltd
Rocician Aries Pharmaceuticals (Pvt) Ltd
Rosiden Medisure Laboratories Pakistan (Pvt.) Ltd.
Roxbex Rakaposhi Pharmaceutical (Pvt) Ltd.
Roxic Everest Pharmaceuticals
Roxic Robins Pharmaceutical Industries
Roxidin Rakaposhi Pharmaceutical (Pvt) Ltd.
Sandan Dispersible Bloom Pharmaceuticals (Pvt) Ltd.
Sandan Dispersible Bloom Pharmaceuticals (Pvt) Ltd.
Simroxy Usawa Pharmaceuticals
Socalm Zesion Pharmaceutical (Pvt) Ltd
Stapirox Standard Drug Co.
Syntec Orta Labs. (Pvt) Ltd.
Tactic Tagma Pharma (Pvt) Ltd.
Tasocam F.M. Pharmaceuticals International
Tasocam-B Tas Pharmaceutical
Textrin Tagma Pharma (Pvt) Ltd.
Traumalax Nenza Pharmaceuticals (Pvt) Limited
Utrahit Unipharma (Pvt) Ltd.
Viepram Tagma Pharma (Pvt) Ltd.
Volika Varioline International (Pvt) Ltd.
Welcame Cherwel Pharmaceuticals (Pvt) Ltd
Weldene Wilshire Laboratories (Pvt) Ltd.
Xycam Mediceena Pharma (Pvt) Ltd.
Zerax Raazee Theraputics (Pvt) Ltd.
Zicam Goodman Laboratories

 

Piroxicam 10 mg Capsules

Biocam Biorex Pharmaceuticals
Brozicam Pliva Pakistan (Pvt) Limited
Caliment Evron (Pvt) Ltd.
Caliment Evron (Pvt) Ltd.
Exican Nova Med Pharmaceuticals
Felcam Cibex (Private) Limited
Feldene Pfizer Laboratories Ltd.
Fycam Fynk Pharmaceuticals
Oram Bryon Pharmaceuticals (Pvt) Ltd.
Oxicam Ipram International
Pcam Merck Private Ltd.
Pirofel Well & Well Pharma (Pvt) Ltd
Piroxicam Jinnah Pharmaceuticals
Poxicam Bio Labs (Pvt) Ltd.
Rheumatus Lotus Pharmaceuticals (Pvt) Ltd
Roxicam Wilsons Pharmaceuticals
Trost Hamaz Pharmaceutical (Pvt) Ltd.

 

Piroxicam 20 mg Capsules

Aksocam Akson Pharmaceuticals (Pvt) Ltd.
Aloxin Alson Pharmaceuticals
Amolive Olive Pharmaceuticals
Arsicam Linear Pharma
Axicam Mass Pharma (Private) Limited
Biocam Biorex Pharmaceuticals
Brexa Aries Pharmaceuticals (Pvt) Ltd
Broksin Universal Pharmaceuticals (Pvt) Ltd
Brozicam Pliva Pakistan (Pvt) Limited
Bruxicam Drugs Inn Pakistan
Caliment Evron (Pvt) Ltd.
Caliment Evron (Pvt) Ltd.
Cam Hisun Pharmaceuticals
Cap-20 Flow Pharmaceuticals (Pvt) Ltd.
Delpirox Rehman Medicine Co.
Delprox Delta Pharma (Pvt) Ltd.
Diodex Pearl Pharmaceuticals
Ericam Zephyr Pharmatec (Pvt) Ltd.
Exican Nova Med Pharmaceuticals
Fapro Farm Aid Group Pak Ltd.
Fedracam Fedro Pharmaceutical
Fedracam Fedro Pharmaceutical
Fedracam Fedro Pharmaceutical
Felaxicam Medera Pharmaceuticals (Pvt) Ltd.
Felcam Cibex (Private) Limited
Feldene Pfizer Laboratories Ltd.
Feloxicam Medera Pharmaceuticals (Pvt) Ltd.
Foster Ferroza International Pharmaceuticals (Pvt) Ltd.
Foster Ferroza International Pharmaceuticals (Pvt) Ltd.
Fycam Fynk Pharmaceuticals
Gel-Cam Imco Pharmaceuticals Laboratories
Gloxi Goodman Laboratories
Indene Shafaz Pharma International (Pvt) Ltd.
Infarel Mercy Pharmaceutical Ltd
Inflacid Gray`S Pharmaceuticals
Inflarox Polyfine Chempharma (Pvt) Ltd.
Jaldin Irza Pharma (Pvt) Ltd.
Maricam Miracle Pharmaceuticals(Pvt) Ltd
Medrox Chas. A. Mendoza
Mobicam Global Pharmaceuticals
Nicep Medisave Pharmaceuticals
Oram Bryon Pharmaceuticals (Pvt) Ltd.
Oxicam Ipram International
Oxyclod Glitz Pharma
Pain-R Rogen Pharmaceuticals
Painles Panacea Pharmaceuticals
Pcam Merck Private Ltd.
Pelcam Z-Jans Pharmaceutical (Pvt) Ltd.
Pharox Valor Pharmaceuticals
Phelodene Unexo Labs (Pvt) Ltd.
Piram Navegal Laboratories
Pirobet Highnoon Laboratories Ltd.
Piroc Bloom Pharmaceuticals (Pvt) Ltd.
Pirofel Well & Well Pharma (Pvt) Ltd
Pirojoint Sayyed Pharmaceuticals
Piromin Medifine Laboratories
Piroxicam Jinnah Pharmaceuticals
Pixicam City Pharma
Poxicam Bio Labs (Pvt) Ltd.
Precam Genome Pharmaceuticals (Pvt) Ltd
Precam-20 Prix Pharmaceutica
Propain Royal Consumer Manufacturing Company
Proxim Novartis Pharma (Pak) Ltd
Pulsecam Pulse Pharmaceuticals
Pyricam Amson Vaccines & Pharma (Pvt) Ltd.
Pyrocam Lowitt Pharmaceuticals (Pvt) Ltd
Rapicam Hygeia Pharmaceuticals
Rheumatus Lotus Pharmaceuticals (Pvt) Ltd
Riacen Chiesi Pharmaceuticals (Pvt) Ltd.
Rosiden Medisure Laboratories Pakistan (Pvt.) Ltd.
Roxicam Wilsons Pharmaceuticals
Roxidin Rakaposhi Pharmaceutical (Pvt) Ltd.
Roxidin Rakaposhi Pharmaceutical (Pvt) Ltd.
Roxsy Winilton Pharmaceuticals (Pvt) Ltd
Rupirox Hizat Pharmaceutical Industries (Pvt) Ltd.
Salden Danas Pharmaceuticals (Pvt) Ltd
Sicam Siam Pharmaceuticals
Sponac Rock Pharmaceuticals
Swatch Tagma Pharma (Pvt) Ltd.
Traumalax Nenza Pharmaceuticals (Pvt) Limited
Trix Trison Research Laboratories (Pvt) Ltd
Trost Hamaz Pharmaceutical (Pvt) Ltd.
Vascam Rasco Pharma
Vincam Obsons Pharmaceuticals
Xegen Shawan Pharmaceuticals