What is the recommended course of naproxen (nonsteroidal anti-inflammatory drug) for the treatment of costochondritis?

Naproxen Course for Costochondritis

For costochondritis, initiate naproxen 500 mg twice daily and evaluate treatment response at 2-4 weeks; if effective, continue therapy with reassessment at 12 weeks, then consider tapering to on-demand use once sustained improvement occurs. 1

Initial Dosing Strategy

• Start with naproxen 500 mg twice daily as the standard initial dose for inflammatory musculoskeletal conditions 2
• The FDA-approved dosing for inflammatory conditions allows 250-500 mg twice daily, with the morning and evening doses not required to be equal 2
• Use the lowest effective dose for the shortest duration consistent with symptom control 2

Treatment Duration and Monitoring

• Assess response at 2-4 weeks to determine if naproxen is providing adequate symptom relief 1
• If sufficient response is achieved, continue treatment and reassess at 12 weeks to determine ongoing need 1
• Consider tapering or switching to on-demand use if sustained improvement occurs, rather than continuing indefinitely 1
• The goal is to minimize exposure while maintaining symptom control, as NSAIDs should not be used continuously beyond what is necessary 1

Critical Safety Precautions

Gastrointestinal Protection

• Add a proton pump inhibitor (PPI) in patients over 65 years old or those with history of peptic ulcer disease 3, 1
• The risk of serious GI bleeding increases significantly with age (1 in 2,100 for those under 45 vs. 1 in 110 for those over 75) 3
• Co-prescription with PPIs reduces NSAID-associated symptomatic ulcers by 50-90% 3

Cardiovascular and Renal Monitoring

• Use naproxen with caution in patients with cardiovascular disease, hypertension, or renal impairment 1
• Naproxen is contraindicated in moderate to severe renal impairment (creatinine clearance <30 mL/min) 2
• NSAIDs can increase mean blood pressure by 5 mm Hg 3
• Avoid in patients with congestive heart failure 3

Important Clinical Pitfalls

• Never combine naproxen with other NSAIDs, as this increases toxicity without improving efficacy 1
• Do not use continuous NSAID therapy indefinitely—the evidence supports time-limited courses with reassessment 1
• Consider adding acetaminophen (paracetamol) rather than increasing naproxen dose, as combination therapy may be more effective than higher NSAID doses alone 4
• If costochondritis is unresponsive to NSAIDs after 2-4 weeks, reconsider the diagnosis—infectious costochondritis requires antibiotics and potentially surgical debridement, not NSAIDs 5

Alternative Considerations

• For severe costochondritis unresponsive to NSAIDs, colchicine has shown success in post-viral cases (particularly post-COVID-19) 6
• Local corticosteroid injections may be considered for refractory cases 3
• Bone pain from naproxen itself can be managed with the same naproxen dose (500 mg twice daily for 5-8 days) if this becomes problematic 3