What is the treatment for costochondritis?

Treatment for Costochondritis

Start with NSAIDs at maximum tolerated dosage as first-line treatment, evaluate response after 2-4 weeks, and consider topical NSAIDs to minimize systemic side effects. 1

First-Line Pharmacological Management

• NSAIDs or COX-2 inhibitors should be initiated at maximum tolerated and approved dosages as the primary treatment approach 1
• Use oral NSAIDs at the lowest effective dose for the shortest possible duration to minimize adverse effects 1
• Topical NSAIDs are preferred when feasible to reduce systemic toxicity, particularly in elderly patients or those with comorbidities 1
• For patients with increased gastrointestinal risk, use either non-selective NSAIDs plus a gastroprotective agent, or a selective COX-2 inhibitor (which reduces serious GI risk by 82%, RR 0.18) 1

Alternative and Adjunctive Pharmacological Options

• Acetaminophen (paracetamol) at regular dosing intervals should be used as an alternative or adjunct when NSAIDs are contraindicated, insufficient, or poorly tolerated 1
• If inadequate response after 2-4 weeks, switch to a different NSAID or add acetaminophen 1
• Short courses of oral prednisolone may be considered as bridging therapy while awaiting effect of other agents 1
• Local corticosteroid injections directed to the specific costochondral junction may be considered for persistent focal pain despite adequate NSAID therapy 1
• Avoid long-term systemic corticosteroids due to lack of evidence supporting their use and significant adverse effect profile 1

Non-Pharmacological Interventions

• Apply local heat or cold applications to the affected area for symptomatic relief 1
• Regular exercise and physical therapy should be incorporated as part of the treatment plan 1
• Stretching exercises have demonstrated progressive significant improvement in pain compared to controls (p<0.001) and can be a useful adjunctive treatment 2
• Advise patients to avoid activities that produce chest muscle overuse 3
• Provide patient education about the benign, self-limited nature of the condition 1

Critical Safety Monitoring

• Monitor for gastrointestinal, hepatic, and cardiorenal toxicity with prolonged NSAID use, especially in elderly patients and those with comorbidities 1
• The risk of serious GI complications with NSAIDs carries a relative risk of 5.36 (95% CI: 1.79-16.10) 1
• Patients older than 35 years or those with cardiac risk factors should have an electrocardiogram to rule out coronary artery disease, which is present in 3-6% of adult patients with chest wall tenderness 3

Common Pitfalls to Avoid

• Never use long-term systemic corticosteroids as they lack evidence for axial/chest wall pain and carry significant adverse effects 1
• Do not assume all anterior chest pain is costochondritis—coronary artery disease must be excluded in appropriate patient populations 3
• Recognize that infectious costochondritis (though rare) requires entirely different management with antibiotics and possible surgical debridement 4