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Inflammopharmacology.1996;4: 125-135. 9 1996KluwerAcademicPublishers.

Printed in the Netherlands



BY MELOXICAM L. C H U R C H I L L , A.G. G R A H A M , C-K. SHIH, D. P A U L E T T I , P.R. F A R I N A and P.M. G R O B Department of Inflammatory Diseases, Boehringer Ingelheim Pharmaceuticals Inc., Ridgefield, CT, USA

ABSTRACT Churchill L, Graham AG, Shih C-K, Pauletti D, Farina PR, Grob PM. Selective inhibition of human cyclo-oxygenase-2by meloxicam. Irdlammopharmacology.1996;4:125-135 Human cyclo-oxygenase-1(hCOX-1) and -2 were expressed in stable transfected COS A.2 cells and in insect cells using a Sf9 baculovirus expression system. Inhibition of COX activity was examined using both whole cell and microsomal assays. Ibuprofen, naproxen, 6-MNA, diclofenac and indomethacin were selectivefor hCOX-1 or were equipotent inhibitors for COX-1 and COX-2. Piroxicamwas equally inhibitory for both enzymes in the whole cell assay while it preferentially inhibited hCOX-2 in the microsomal assay. However, maximal inhibition of hCOX-2 by piroxicam plateaued at 60%. Nimesulide was equipotent in the whole-cell assay but was five-fold selective for hCOX-2 in the microsomal assay. Meloxicampreferentially inhibited hCOX-2in the whole cell assay at concentrations of 0.01 to 1 lmaol/L but was an equipotent inhibitor of both enzymesat higher concentrations. In the microsomal assay, meloxicam exhibited high selectivity for hCOX-2 (75-fold). The preferential inhibition of hCOX-2 by meloxicam may explain the favourable gastrointestinal profile observed for meloxicam compared with other NSAIDs.


INTRODUCTION Prostaglandins are lipid mediators whose production is enhanced in both acute and chronic inflammatory reactions. It is well known that the mechanism of action of nonsteroidal anti-inflammatory drugs (NSAIDs) is principally by the inhibition of cyclooxygenase, thus blocking the production of proinflammatory prostaglandins [1]. In 1990, Fu and colleagues reported that the enhanced cyclo-oxygenase activity observed in endotoxin-stimulated human monocytes was associated with de-novo synthesis of cyclo-oxygenase protein [2]. In subsequent years, it was established that two isoforms of cyclo-oxygenase exist [3,4]. COX-1 is constitutively expressed in most tissues and is considered to be involved in the production of prostaglandins required for normal physiological function (e.g. maintenance of gastric mucosa and normal renal function) [5]. COX-2 is transcriptionally induced in response to inflammatory stimuli, such as cytokines and endotoxin, in several cell types including monocytes, fibroblasts and synovial cells [6-8]. Increased COX-2 expression has been demonstrated at inflammatory sites in various animal models of inflammation and arthritis [9,10]. The induction of COX-2 during inflammatory reactions may be responsible for the production of pro125


Churchill et al.

inflammatory prostaglandins. Thus, inhibition of COX-I may contribute to the classical gastrointestinal side-effects and renal toxicity associated with NSAIDs while the inhibition of COX-2 may be responsible for the therapeutic effects of NSAIDs. Meloxicam is an enolic-acid-derived NSAID, developed for use in rheumatoid and osteoarthritis. Preclinical studies have demonstrated that meloxicam is a potent antiinflammatory agent in several animal models of acute and chronic inflammation [11,12]. The ratio of the ulcerogenic potential to the anti-inflammatory activity of meloxicam indicates that meloxicam has an improved therapeutic index compared with other NSAIDs. The improved therapeutic margin that is observed with meloxicam may be due to preferential inhibition of COX-2 over COX-1. The present study was conducted to examine the inhibitory profiles of meloxicam and other selected NSAIDs on human recombinant COX-1 and COX-2.

MATERIALS AND METHODS Materials Cell culture media and reagents were purchased from Gibco BRL (Grand Island, NY). Leupeptin, soybean trypsin inhibitor, PMSF, aprotinin, haematin, phenol, reduced glutathione, arachidonic acid, diclofenac-sodium salt, naproxen, piroxicam, ibuprofen, nimesulide and indomethacin were purchased from Sigma Chemical Co. (St. Louis, MO). Aspirin was purchased from Aldritch Chemical Co. (Milwaukee, WI). 6-MNA (6-methoxy-2-naphthylacetic acid), the active metabolite of nabumetone, was synthesized according to published methods [13]. Meloxicam was synthesized at the laboratories of Dr. Karl Thomae GmbH (Biberach, Germany). Restriction enzymes were obtained from New England Biolabs (Beverly, MA).

Expression of human COX-1 and COX-2 in stable transfected cell lines Human COX-1 and hCOX-2 cDNA clones and stable transfected cell lines were obtained from D.A. Young (University of Rochester, NY). Briefly, hCOX-I and hCOX-2 cDNA clones were isolated from a cDNA library prepared from a human fibroblast cell line (W138) that was treated with serum and cycloheximide for 4 h. Polymerase chain reaction (PCR) primers were engineered to amplify the coding regions specific for either the hCOX-1 or hCOX-2 sequences. The 5' end primers contained a HindlII restriction site and the 3' end primers contained a NotI restriction site. Reverse transcriptase-PCR using the specific primers generated PCR products of approximately 2 kb. Following purification and digestion with HindllI and NotI, PCR products were ligated into a pCR/CMV vector (Invitrogen, San Diego, CA). Ligated pCR/CMV:hCOX recombinants were isolated and screened by restriction mapping. Selected hCOX-1 and hCOX-2 clones were sequenced in both directions to confirm that the correct sequences were present. COS A.2 cells were transfected with pCR/ CMV:hCOX-1 or hCOX-2 by calcium phosphate precipitation. The exclusive presence

Inhibition of Cyclo-oxygenase-2by Meloxicam


of either hCOX- 1 or hCOX-2 in the cell lines was confirmed by Northern analysis using hybridization probes that were specific for either hCOX-1 or hCOX-2. COS A.2 cell lines expressing either hCOX-I or hCOX-2 were cultured in 96-well tissue culture plates with Dulbecco's Modified Eagle Medium supplemented with 10% fetal bovine serum, glutamine (2 mmol/L), penicillin (50 U/ml), streptomycin (50 rag/ ml) and geneticin (400 ~tg/ml).

Whole cell cyclo-oxygenase activity assay Medium was removed from confluent cell cultures and was replaced with Hank's balanced salt solution. Test compound or the appropriate DMSO vehicle (control) was added to each well and allowed to incubate for 30 rain at 37~ Arachidonic acid (30 ~tmol/L) was then added to the cells and the incubation continued for an additional 1 h (total volume 100 ~tl). Supernatants were removed and were analysed for PGE2 by EIA (RPN222, Amersham, Arlington Heights, IL). Control levels of PGE2 were 7.19-I- 1.66 ng/ml and 1.75 __+ 0.31 ng/ml for hCOX- 1 and hCOX-2, respectively.

Expression of hCOX-1 and hCOX-2 genes in a baculovirus system Human COX-1 and hCOX-2 cDNA clones were obtained from D.A. Young (U. Rochester) as described above and were subcloned into pVL 1393 transfer vector for expression in the baculovirus system. Briefly, the clones were first digested with HindllI, end-filled with Klenow, and digested again with XbaI in order to prepare the fragments containing hCOX-1 or hCOX-2 genes to be ligated into the baculovirus transfer vector. The desired gene fragments were then ligated into pVL 1393 vector via Sinai and XbaI sites. The positive clones were identified by restriction enzyme digestions, and further confirmed by DNA nucleotide sequencing. The hCOX-1 or hCOX-2 pVL 1393 plasmids were transfected with linearized AcMNPV baculovirus DNA into Sf9 insect cells using the Insectin kit (Invitrogen, San Diego, CA) according to the manufacturer's instructions. Viral clones were screened for cyclo-oxygenase activity to identify clones containing active cyclooxygenase genes. Briefly, whole cell assays were carried out by adhering Sf9 cells 1 x 105 per well in 96-well microtitre plates, infecting with viral stocks and incubating for three days. Cyclo-oxygenase activity was then measured by the addition of arachidonic acid (30 Ignol/L) to the cells for I h at 27~ The supernatants were then analysed for PGF-a as described above. The presence of cyclo-oxygenase proteins in the positive clones was further confirmed by Western blot analysis of cell lysates with polyclonal antibodies against cyclo-oxygenase proteins (Cayman, Ann Arbor, MI). Single clones for both hCOX-1 and hCOX-2 genes were chosen for large-scale preparation of cyclo-oxygenase proteins. Viral stocks were prepared by infecting a litre of Sf9 cells, titred by plaque assays, and used for infecting either 15 or 30 L of High Five insect cells (Invitrogen). Microsomes were prepared from High Five insect cells (Invitrogen) three days post-


Churchill et al.

infection. Cell pellets were resuspended in homogenization buffer consisting of 0.1 mol/L Tris buffer (pH 7.4) containing EDTA (10 mmol/L), PMSF (1 mmol/L), leupeptin (2 lig/ml), soybean trypsin inhibitor (2 Ixg/ml) and aprotinin (2 lxg/ml). Cells were sonicated and centrifuged at 10 000g for 10 min. The supernatant was removed and was centrifuged at 100 000g for 1 h and 30 min. The resulting microsomal pellet was resuspended in 0.1 mol/L Tris buffer (pH 7.4) containing 30% glycerol. Microsomal preparations were stored at -80~

Microsomal cyclo-oxygenase activity assay

Microsomes (3.5 and 0.4 tig protein/per well, for hCOX-1 and hCOX-2 microsomal preparations, respectively) were incubated with haematin (2 ~tmol/L), phenol (0.5 mmol/L), reduced glutathione (1 mmol/L) for 5 min at room temperature. Test compound or the appropriate DMSO vehicle (control) was then added and the mixture was preincubated for 20 min before the addition of arachidonic acid (2 ~tmol/L). The total reaction volume was 200 lal. The reaction was stopped at 20 min by the addition of HC1 (0.1 N HC1, final concentration). Samples were diluted in EIA buffer containing 25 limol/L indomethacin and analysed for PGE2 by EIA (RPN222, extended range protocol, Amersham). Control levels of PGE2 were 6.43 + 1.86 and 6.94_ 1.94 ng/ml for hCOX- 1 and hCOX-2, respectively.

Data analysis
Each drug concentration was tested in triplicate wells for the COS cell experiments, or duplicate wells for the microsomal experiments within the individual experiments. Data are presented as the mean of n/> 3 individual experiments. Results are expressed as ~ inhibition of control PGE2 production +__ standard error. Dose-response curves were analysed by non-linear regression (Hill equation) using SAS Software System (SAS Institute, Inc., Cary, NC) [14,15]. The calculated ICso value is the concentration of the drug that caused a 50% decrease in the maximal inhibition of cyclo-oxygenase activity as measured by PGE2 production.

RESULTS The profiles of inhibition by meloxicam and other selected NSAIDs on the two isoforms of hCOX were determined using COS A.2 ceils that were stably transfected with hCOX-1 or hCOX-2 in a whole-cell assay. Dose-response curves for meloxicam, piroxicam, ibuprofen and naproxen are shown in Figure 1. Meloxicam was a more potent inhibitor of hCOX-2 than hCOX-1 at concentrations that produced 60% maximal inhibition of PGE2 or less (0.01-1 limol/L). However, at concentrations that produced > 60% inhibition, meloxicam was equipotent in its inhibition of hCOX-1 and hCOX-2. In contrast with that of meloxicam, piroxicam was equipotent in its

Inhibitionof Cyclo-oxygenasc-2 by Meloxicam


100 80 60 40 LLI 13... v

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80 6O 40 20 0

, .~

20 0

10-2 10-1 10 o 101

10 2 10 3

10-2 10-1 10o 101 102 103 100

D 9

100 80 60 40 20 0 10-2 10-1 10o 101 102 103 C m .~ m , i ~ I


246 80 0 00

10-2 10-1 10 o 101 10 2 10 3

Figure 1. Dose-response curves for inhibition of hCOX-1 (-O-) and hCOX-2 (-II-) by meloxicam (A), piroxicam (B), ibuprofen (C) and naproxen (D) using Cos A.2 cells that were stably transfected with recombinant hCOX-1 or hCOX-2 in a whole-cell assay as described in Materials and Methods. Data represent the mean__+standard error of nl> 3 individual experiments

inhibition of hCOX-1 and hCOX-2 at doses that produced 60% maximal inhibition or less (0.01-1 lamol/L), but was a more potent inhibitor of hCOX-1 at higher doses. Naproxen and ibuprofen were more selective as inhibitors of hCOX-1. Results of nonlinear regression analysis of the concentration-response curves for meloxicam and the selected NSAIDs tested in the whole-cell assay are shown in Table 1. The different slopes of the hCOX-1 versus the hCOX-2 meloxicam concentration-response curves, as is indicated by their Hill coefficients (0.97 vs. 0.50, respectively), precludes direct comparison of ICs0 values. Comparison of the IC50 values of the other NSAIDs tested demonstrates that piroxicam, nimesulide and diclofenac were approximately equipotent while ibuprofen, naproxen, 6-MNA, indomethacin and aspirin were selective inhibitors of hCOX- 1. Cyclo-oxygenase inhibitory activity of the standard compounds were also examined


Churchill et al.

TABLE 1 ICs0 values for the inhibition of recombinant hCOX-1 and hCOX-2 expressed in stable transfected COS cells using a whole-cell assay COX- 1 NSAID Meloxicam Piroxicam Ibuprofen Naproxen Nimesulide 6-MNA Diclofenac Indomethacin Aspirin
Imax =

COX-2 Imax 84 80 90 82 96 92 94 105 IC5o (tanol/L) 0.16 (0.09-0.22) 0.98 (0.11-1.84) 15.72 (3.57-27.87) 7.08 (0.02-14.14) 0.36 (0.05-0.67) > 300a 0.001 (0.0009-0.0012) 0.030 (0.026-0.034) 16.03 (11.14-20.93)

Imax 91 102 100 104 98 91 96 96 108

IC5o (grnol/L) 2.24 (1.59-2.88) 2.03 (0.90-3.17) 2.26 (1.60-2.93) 0.33 (0.17-0.49) 1.61 (0.53-2.69) 8.40 (3.45-13.35) 0.0026 (0.0018-0.0035) 0.019 (0.016--0.022) 4.70 (3.24-6.15)

maximal % inhibition of control PGE2 production obtained for a specificcompound. IC50 is the concentrationof the drug that causes a 50% decreasein the maximal inhibitionof cyclo-oxygenaseactivity. Values are reported as the mean of n/> 3 individualexperimentswith 95% confidenceintervals. aEstimated IC5ovalue. Non-linearregression analysis did not converge

in the baculovirus expressed hCOX-1 and hCOX-2 microsomal assay system. Concentration-response curves for meloxicam, piroxicam, naproxen and ibuprofen are shown in Figure 2. Inhibition of both hCOX-1 and hCOX-2 activity by meloxicam was concentration dependent. In contrast with results obtained in the COS cell assay, the linear portions of the meloxicam concentration-response curves were parallel in the microsomal assay. Meloxicam was clearly a more potent inhibitor of hCOX-2 than hCOX-1 under these conditions. Although piroxicam was a more potent inhibitor of hCOX-2 than hCOX-1, maximal inhibition of hCOX-2 activity plateaued at 60% while maximal inhibition of hCOX-1 was >80%. Concentration-response curves for ibuprofen and naproxen demonstrated that these compounds were more potent inhibitors of hCOX-1 than hCOX-2. Comparisons of the calculated IC50 values demonstrates that, under these conditions, meloxicam was a selective inhibitor of hCOX-2 (IC50 ratio hCOX-2/hCOX- 1; 0.013). Nimesulide also preferentially inhibited hCOX-2 (ICs0 ratio hCOX-2/hCOX-1; 0.2). Diclofenac was an equipotent inhibitor of hCOX-1 and hCOX-2 while ibuprofen, naproxen, indomethacin and 6-MNA were selective for hCOX-1 (Table 2). Aspirin was also selective for hCOX-1 in the microsomal assay. However, it was not a very potent inhibitor of either hCOX-1 or hCOX-2 (IC50 > 100 I~mol/L, data not shown).

Inhibition of Cyclo-oxygenase-2by Meloxicam


100 80 60 40

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10 2 10 3

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100 80 60 40 20 0

100 80 60 40


10"2 10"1 10 0 101 10 2 10 3 10-2 10-1 10 0 10 ~ 10 2 10 3

Figure 2. Dose-response curves for inhibition of hgOX-1 (-O-) and hCOX-2 ( - I - ) by rneloxicam (A), piroxicam (B), ibuprofen (C) and naproxen (D) using microsomes from insect cells as described in Materials and Methods. Data represent the mean 4-standard error of n >~3 individual experiments

DISCUSSION The recent discovery of two isoforms of cyclo-oxygenase has led to the hypothesis that the gastrointestinal and renal toxicity of NSAIDs are due to the inhibition of constitutively expressed COX-1, while the anti-inflammatory properties are due to the inhibition of the inducible form of the enzyme, COX-2 [9]. Thus, compounds that selectively inhibit COX-2 may have superior gastrointestinal and renal safety profiles than those non-selective or COX-l-selective compounds. We have evaluated the ability of selected NSAIDs to preferentially inhibit hCOX-2 using recombinant human enzymes. Several previously published reports have examined the cyclo-oxygenase inhibition profiles of NSAIDs in whole-cell assay systems. However, interpretation and comparison of the results of these studies is complicated by the different assay conditions,


Churchill et al.

TABLE 2 ICs0 values for the inhibition of recombinant hCOX-1 and hCOX-2 expressed in insect cells using a microsomal assay system COX- 1 COX-2 Imax IC50 (lunol/L)



IC5o (Imaol/L)

Meloxicam Ibuprofen Naproxen Nimesulide 6-MNA Diclofenac Indomethacin

88 108 104 101 100

36.6 (26.4-46.8) 13.88 (6.13-21.63) 2.7 (1.9-3.4) ~ 50a /> 100a 0.059 (0.033-0.085) 0.10 (0.07-0.13)

79 100 b 98 100

0.49 (0.39-0.57) ~80 a ~ 50 a 9.4 (5.7-13.2) NA 0.031 (0.022-0.040) 0.35 (0.32-0.39)

Imax= maximal % inhibition of control PGE2 production obtained for a specificcompound. ICs0 is the concentration of the drug that causes a 50%~ decreasein the maximal inhibition of cyclo-oxygenaseactivity. Values are reported as the mean of n >_, individual experiments with 95% confidence intervals. 3 aEstimated IC5ovalue. Non-linear regression analysis did not converge blm~xfixed at 100% NA: < 20% inhibition at 300 larnol/L

species and cell types that have been used. Mitchell and colleagues, using bovine endothelial cells as a source of COX-1 and a lipopolysaccharide-stimulated murine macrophage cell line as a source of COX-2, have reported that indomethacin and ibuprofen are selective inhibitors of COX-1 while naproxen and diclofenac are equipotent inhibitors of COX-1 and COX-2 [16]. However, a recent study by Grossman and colleagues has reported selective inhibition of hCOX-2 activity by naproxen, indomethacin, piroxicam and diclofenac using human platelets (COX-l) and lipopolysaccharide-stimulated human monocytes (COX-2) [17]. Although the relative order of potency of inhibitors against the cyclo-oxygenase activity in a particular cell type can be determined, it is not clear that comparison of the potency of a compound between cell types is only dependent on the specific isotype of the enzyme expressed in each cell. We have examined the ability of meloxicam and several N S A I D s to inhibit hCOX-1 and hCOX-2 expressed in stable transfected COS A.2 cells in a whole-cell assay system. Ibuprofen, naproxen, 6-MNA, indomethacin and aspirin selectively inhibited hCOX-1 while diclofenac, nimesulide and piroxicam were approximately equipotent inhibitors ofhCOX-1 and hCOX-2. The inhibition profile of meloxicam on hCOX-1 and hCOX2 in the whole-cell assay was unique among the compounds studied. Selectivity of meloxicam for the two enzymes was dependent on the dose of the compound tested. Meloxicam selectively inhibited hCOX-2 at lower doses but was an equipotent

Inhibition of Cyclo-oxygenase-2by Meloxicam


inhibitor at higher doses. Our results are consistent with a previous report of the preferential inhibition by meloxicam of COX-2 using unstimulated (COX-l) and lipopolysaccharide-stimulated (COX-2) guinea-pig macrophages [18]. The present study also examined the cyclo-oxygenase selectivity of specific NSAIDs using microsomal preparations from insect cells expressing hCOX in a baculovirus expression system. Consistent with recent reports, we observed a general trend toward a decrease in the potency of the NSAIDs tested in the microsomal assay system compared with that in the whole-cell assay system [19]. However, the relative cyclooxygenase selectivity of most of the compounds examined was similar in both the whole-cell and microsomal assay systems. Our results show that indomethacin, ibuprofen, 6-MNA and naproxen were selective inhibitors of hCOX-1 while diclofenac was an equipotent inhibitor of hCOX-I and hCOX-2. Similar inhibition profiles have been reported for these compounds in studies using baculovirus- and vaccinia-virusexpressed hCOX in microsomal assay systems [ 19-21]. Interpretation of the inhibition profile of piroxicam is complicated by the observation that maximal inhibition of hCOX-2 by piroxicam was significantly lower than maximal inhibition of hCOX-1. O'Neill and colleagues have reported that piroxicam was not a very potent inhibitor of vaccinia-virus-expressed hCOX-1 (IC50 = 300 ~tmol/L) or hCOX-2 (IC50 > 300 ~tmol/ L) [20]. Our results suggest that at higher concentrations piroxicam may selectively inhibit hCOX-1. The differences in the effects of piroxicam in the two systems might be attributed, in part, to microsomal metabolism of this drug. The selective inhibition of hCOX-2 by nimesulide is consistent with a previous report by Barnett et al. [19]. However, the degree of selectivity for hCOX-2 reported in this study is significantly less than that reported by Barnett and colleagues. This discrepancy may be due to differences in the incubation times used, since nimesulide has been shown to be a time-dependent inhibitor [19]. Compared with the other NSAIDs tested in the present study, meloxicam was highly selective for hCOX-2 in the microsomal assay system. Unlike the results from the whole-cell assay, however, selectivity of meloxicam for hCOX-2 in the microsomal assay was consistent over the entire concentrationresponse curve. Meloxicam is known to be highly protein bound [22]. Because more microsomal protein was used in the hCOX-1 assay than in the hCOX-2 assay, it might be possible that the decreased potency of meloxicam in the hCOX-1 assay was due to increased protein binding. However, when microsomal protein from uninfected cells was added to the hCOX-2 microsomal preparation to match the protein concentration in the hCOX-1 assay, the meloxicam concentration-response curve for hCOX-1 was unchanged (data not shown). This suggests that preferential inhibition of hCOX-2 by meloxicam is not due to variations in protein binding in the assay systems. Pre-clinical studies have demonstrated that meloxicam is a potent anti-inflammatory agent in animal models of acute inflammation and arthritis. Engelhardt and colleagues have reported that meloxicam significantly inhibits carageenan-induced paw oedema in the rat and both the primary and secondary responses in the rat adjuvant-induced arthritis model [11,12]. The ratio of the ulcerogenic potential of meloxicam compared with the anti-inflammatory activity shows that meloxicam has a superior therapeutic index compared with other standard NSAIDs tested. Furthermore, clinical trials have demonstrated a favourable gastrointestinal safety profile for meloxicam [23]. This


Churchill et al.

study supports the hypothesis that selective inhibition of COX-2 by meloxicam may contribute to the improved therapeutic index and safety profile that has been observed for meloxicam in vivo.

ACKNOWLEDGEMENTS The authors would like to thank Edward Graham for assistance with SAS analysis of the data and Sheri Rogers for technical assistance.

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18. Engelhardt G, Pariet M. Meloxicam: A new NSAID with an improved safety profile through preferential inhibition of COX-2. Rheumatol Eur. 1995;24(suppl 3):D203. 19. Barnett J, Chow J, Ives D et al. Purification, characterization and selective inhibition of human prostaglandin G/H synthase 1 and 2 expressed in the baculovirus system. Biochim Biophys Acta. 1994; 1209:130-9. 20. O'Neill GP, Mancini JA, Kargman Set al. Overexpression of human prostaglandin G/H synthase-1 and -2 by recombinant vaccina virus: Inhibition by nonsteroidal antiinflammatory drugs and biosynthesis of 15-hydroxyeicosatetrenoic acid. Mol Pharmacol. 1995;45:245-54. 21. Glaser K, Sung ML, O'Neil K et al. Etodolac selectively inhibits human prostaglandin G / H synthase 2 (PGHS-2) versus human PGHS-1. Eur J Pharmacol. 1995;281:107-11. 22. Turck D, Busch U, Heinzel G, Narjes H. Clinical pharmacokinetics of meloxicam. Eur J Rheumatol Inflamm. 1996;15:23-30. 23. Distel M, Mueller C, Blumkhi E. Global analysis of safety of a new NSAID, meloxicam. Rheumatol Eur. 1995;24(suppl 3):E259. Manuscript received 22 Jan. 96. Accepted for publication 30 Jan. 96.