What is the recommended dose and duration of naproxen (Nonsteroidal Anti-Inflammatory Drug (NSAID)) for the treatment of costochondritis?

Naproxen Dosing and Duration for Costochondritis

For costochondritis, naproxen should be dosed at 500 mg twice daily (or 250 mg every 6-8 hours for milder cases), used at the lowest effective dose for the shortest duration necessary—typically 2-4 weeks with reassessment, and should not exceed 1000 mg daily for ongoing treatment. 1

Specific Dosing Recommendations

Initial Dosing

• Start with naproxen 500 mg twice daily for acute costochondritis pain, as this inflammatory condition responds to standard anti-inflammatory dosing 1
• Alternative regimen: 250 mg every 6-8 hours may be used for less severe cases 1
• The initial total daily dose should not exceed 1250 mg on day one, with subsequent days limited to 1000 mg daily maximum 1

Duration of Treatment

• Evaluate treatment response at 2-4 weeks, as recommended for inflammatory musculoskeletal conditions 2
• If sufficient response is achieved, continue treatment and reassess at 12 weeks 2
• Consider tapering or switching to on-demand use if sustained improvement occurs 2
• Most costochondritis cases resolve within several weeks to months with appropriate treatment 3, 4

Treatment Algorithm

Week 0-2: Initial Phase

• Initiate naproxen 500 mg twice daily (or 250 mg every 6-8 hours) 1
• Use the lowest effective dose that controls symptoms 2, 1
• Assess pain relief within 24-48 hours; onset of action typically begins within 1 hour 1

Week 2-4: Early Reassessment

• If insufficient response: Consider NSAID rotation to a different agent (e.g., ibuprofen 800 mg three times daily) or increase to maximum tolerated dose 2
• If adequate response: Continue current dose and plan reassessment at 12 weeks 2

Week 12+: Long-term Management

• If sustained improvement: Taper to lowest effective dose or switch to as-needed dosing 2
• If persistent symptoms: Re-evaluate diagnosis and consider alternative or adjunctive therapies (physical therapy, stretching exercises) 3, 4

Critical Safety Considerations

Gastrointestinal Protection

• In patients with increased GI risk (age >65, history of ulcers, concurrent corticosteroid use): Add a proton pump inhibitor or consider a COX-2 selective agent 2
• The risk of serious GI toxicity is dose-dependent and increases with age 2

Cardiovascular and Renal Risks

• Use with caution in patients with cardiovascular disease, hypertension, or renal impairment 2, 1
• Naproxen is contraindicated in moderate to severe renal impairment (creatinine clearance <30 mL/min) 1
• Elderly patients may require dose reduction due to increased unbound plasma fraction 1

Duration Limits

• Avoid long-term continuous use beyond what is necessary for symptom control 2
• Periodic re-evaluation of the need for continued NSAID therapy is essential 2

Common Pitfalls to Avoid

• Do not exceed 1000 mg daily for maintenance therapy (1250 mg only on first day) 1
• Do not combine with other NSAIDs, as this increases toxicity without improving efficacy 5
• Do not continue indefinitely without reassessment—costochondritis typically resolves with time and appropriate treatment 3, 4
• Do not ignore the role of non-pharmacologic therapy—stretching exercises and physical therapy show significant benefit and should be incorporated early 3, 4

Adjunctive Considerations

While NSAIDs like naproxen are first-line pharmacologic treatment for costochondritis 6, physical therapy with manual therapy and stretching exercises demonstrates clinically meaningful improvement (mean pain reduction of 5.1 points on 0-10 scale) and should be considered early, particularly for cases lasting beyond 4-6 weeks 3, 4