What is the role of prednisone (corticosteroid) in treating costochondritis?

Role of Prednisone in Treating Costochondritis

Prednisone should be reserved as a second-line treatment for moderate to severe costochondritis that fails to respond to first-line therapies such as NSAIDs, as it shows significant efficacy but carries substantial risks of adverse effects.

Evidence for Prednisone in Costochondritis

While there are no comprehensive clinical guidelines specifically addressing prednisone use in costochondritis, we can draw insights from the available evidence:

• A recent randomized controlled trial demonstrated that adding oral prednisone (40mg daily for 1 week, followed by 20mg daily for 1 week, then 10mg daily for 1 week) to NSAID therapy resulted in significantly greater pain reduction compared to NSAIDs alone (65.4% vs. 46.7% reduction at 3 weeks, p<0.001) 1
• This benefit was maintained at medium-term follow-up (median 6.5 months), with a 25.8% greater reduction in pain scores in the steroid group 1
• Quality of life measures also showed significant improvement with the addition of prednisone 1

Treatment Algorithm for Costochondritis

First-line therapy:

1. NSAIDs for 2-3 weeks
2. Local heat application
3. Activity modification and stretching exercises 2
4. Reassessment after 2-3 weeks

Second-line therapy (for patients who fail to respond to first-line treatment):

1. Short course of oral prednisone (40mg daily for 1 week, then 20mg daily for 1 week, followed by 10mg daily for 1 week) 1
2. Consider ultrasound-guided local corticosteroid injection for focal costochondritis 3

Important Considerations When Using Prednisone

Risks and Adverse Effects

Corticosteroids carry significant risks that must be weighed against potential benefits:

• Increased risk of serious infections (hazard ratio 1.57) 4
• Increased mortality risk (hazard ratio 2.14) 4
• Metabolic disturbances including hyperglycemia and hypokalemia 5
• Osteoporosis risk, especially with prolonged use 5
• Adrenal suppression in approximately 50% of patients on medium/high-dose therapy 5
• Cardiovascular risks including hypertension 5

Risk Mitigation Strategies

If prednisone is prescribed:

• Use the lowest effective dose for the shortest duration possible 5
• Consider calcium (800-1000mg daily) and vitamin D (800 IU daily) supplementation 5
• Monitor blood glucose and potassium regularly 5
• Taper gradually when discontinuing to prevent adrenal insufficiency 5
• Avoid in patients with poorly controlled diabetes, history of steroid-induced psychosis, severe osteoporosis, or prior severe steroid side effects 4

Special Considerations

• Duration: Limit prednisone use to short courses (typically 3 weeks) to minimize adverse effects 1
• Monitoring: Assess response at 1-2 weeks to determine if continued therapy is warranted
• Alternative treatments: For patients with localized costochondritis, consider ultrasound-guided local corticosteroid injection as an alternative to oral prednisone 3
• Refractory cases: For patients with persistent symptoms despite prednisone, consider referral to a specialist for further evaluation

Conclusion

While prednisone can be effective for treating moderate to severe costochondritis that doesn't respond to NSAIDs, its use should be limited to short courses due to the significant risk of adverse effects. The evidence supports a 3-week tapering course (40mg → 20mg → 10mg) when used, with careful monitoring for response and side effects.