Is Indocin (indomethacin) still the drug of choice for treating costochondritis?

Treatment of Costochondritis: Current Recommendations for Pain Management

No specific NSAID, including indomethacin (Indocin), is recommended as the preferred drug of choice for treating costochondritis. 1 The selection of NSAID should be based on the patient's past history of NSAID use, risk factors for adverse effects, and comorbidities.

First-Line Treatment Options

NSAIDs are strongly recommended as the first-line treatment for costochondritis:

• Any NSAID can be effective - Multiple head-to-head controlled trials have shown no evidence to suggest that indomethacin has different effects on pain or stiffness compared to other NSAIDs 1
• Ibuprofen: 400-800mg three times daily for 7-10 days (maximum daily dose: 2400-3200mg) 2
• Naproxen: 500mg twice daily, which may be preferred for patients needing more sustained relief due to its longer half-life 2
• Acetaminophen (Paracetamol): Can be used as an alternative, up to 3000mg daily divided into 3-4 doses 2

Treatment Duration and Monitoring

• Initial treatment should be for 7-10 days
• Assess for pain relief after 3-5 days
• If no improvement is seen after 7 days, consider alternative treatments 2
• Clinical reassessment at 2-4 weeks to evaluate efficacy

Special Considerations

For Patients with GI Risk Factors:

• COX-2 selective inhibitors like celecoxib decrease the risk of gastrointestinal events by approximately 50% compared to non-selective NSAIDs 2
• Meloxicam may be preferred over ibuprofen due to its better GI safety profile 2
• Add a proton pump inhibitor (e.g., omeprazole 20mg daily) for patients:
  • Over 65 years of age
  • With history of peptic ulcer disease
  • Taking concomitant aspirin, anticoagulants, or corticosteroids
  • Requiring high-dose or prolonged NSAID therapy 2

For Patients with Cardiovascular Risk:

• Naproxen is preferred for patients taking low-dose aspirin for cardioprotection, as ibuprofen may interfere with aspirin's cardioprotective effects 2
• Use the lowest effective dose for the shortest duration needed 2

Alternative Treatments for Refractory Cases

For patients with persistent symptoms despite NSAID therapy:

• Local corticosteroid injections have shown symptomatic improvement in patients with recurrent costochondritis 3
• Sulfasalazine may be beneficial for recurrent costochondritis cases - 10 out of 11 patients with recurrent symptoms responded to sulfasalazine in one study 3

Safety Precautions

• Monitor for adverse effects, particularly gastrointestinal and cardiovascular
• Advise patients to minimize or eliminate alcohol consumption, as it significantly increases NSAID-associated GI bleeding risk
• Avoid using multiple NSAIDs simultaneously 2
• Monitor blood pressure within 1-2 weeks of starting therapy
• Check renal function periodically, especially in at-risk patients 2

Common Pitfalls to Avoid

1. Misdiagnosis: Ensure costochondritis is distinguished from more serious causes of chest pain. Coronary artery disease is present in 3-6% of adult patients with chest pain and chest wall tenderness 4
2. Overtreatment: Using NSAIDs for longer than necessary increases risk of adverse effects
3. Undertreatment: Inadequate pain control may lead to activity limitation and prolonged recovery
4. Missing cardiac causes: Patients older than 35 years, those with a history or risk of coronary artery disease, and any patient with cardiopulmonary symptoms should have an electrocardiograph and possibly a chest radiograph 4

In conclusion, while indomethacin has historically been used for costochondritis, current evidence does not support it as being superior to other NSAIDs. The choice of NSAID should be individualized based on patient factors, with all NSAIDs considered equally effective for pain management in costochondritis.