Costochondritis Treatment and Discharge Instructions
Start with NSAIDs at maximum tolerated dose as first-line treatment, reassess at 2-4 weeks, and provide reassurance that this is a self-limiting condition that typically resolves within weeks to months. 1
Pharmacological Management
First-Line Treatment
- Initiate NSAIDs/COXIBs at maximum tolerated and approved dosage as the primary treatment for costochondritis 1
- Evaluate treatment response at 2-4 weeks; if insufficient response, consider rotating to a different NSAID 1
- Use the lowest effective dose for the shortest possible duration to minimize gastrointestinal, cardiovascular, and renal risks 1
- Consider topical NSAIDs to minimize systemic side effects, particularly in elderly patients or those with comorbidities 1
Alternative and Adjunct Options
- Acetaminophen (paracetamol) at regular dosing intervals may be used as an alternative or adjunct when NSAIDs are contraindicated, insufficient, or poorly tolerated 1
- For patients with increased gastrointestinal risk, use non-selective NSAIDs plus a gastroprotective agent (PPI or H2-blocker), or switch to a selective COX-2 inhibitor 1
Bridging Therapy for Severe Cases
- Short courses of oral prednisolone may be considered as a bridging option while awaiting the effect of NSAIDs, but avoid long-term glucocorticoid use 1
- Local corticosteroid injections directed to the specific costochondral junction may be considered for persistent focal pain despite adequate NSAID therapy 1
Non-Pharmacological Interventions
- Apply local heat or cold applications to the affected costochondral area for symptomatic relief 1
- Advise temporary rest and avoidance of activities that produce chest muscle overuse or repetitive movements 2
- Provide patient education about the benign, self-limiting nature of costochondritis 1, 2
- Consider physiotherapy or osteopathic manipulation techniques for cases that do not self-resolve within the expected timeframe 3
Discharge Instructions
Expected Course
- Reassure patients that costochondritis is typically self-limiting and resolves within a few weeks, though some cases may persist longer 2
- Approximately 55% of patients may still experience some chest pain at 1 year, but only one-third will have definite costochondritis 4
Red Flag Symptoms Requiring Immediate Return
- Worsening or changing chest pain that differs from the reproducible costochondral tenderness
- Shortness of breath, palpitations, or diaphoresis
- Fever or signs of infection (important to distinguish from infectious costochondritis) 5
- Pain not reproduced by palpation of the chest wall
Follow-Up Plan
- Schedule reassessment at 2-4 weeks to evaluate treatment response 1
- If no improvement or worsening at 2-4 weeks, consider NSAID rotation or alternative diagnoses 1
- For persistent symptoms beyond expected timeframe, consider referral for physical therapy or manipulation techniques 3
Critical Safety Considerations
NSAID Monitoring
- Monitor for gastrointestinal, hepatic, and cardiorenal toxicity with prolonged NSAID use, particularly in elderly patients and those with diabetes, hypertension, or renal disease 1
- Avoid NSAIDs in patients with active peptic ulcer disease, severe renal impairment, or recent cardiovascular events 6
Avoiding Common Pitfalls
- Do not diagnose costochondritis without first ruling out cardiac causes in patients over 35 years, those with cardiac risk factors, or any patient with cardiopulmonary symptoms 2
- Coronary artery disease is present in 3-6% of adult patients with chest pain and chest wall tenderness 2
- Avoid long-term systemic corticosteroids, which lack evidence for efficacy and carry significant adverse effects 1
- Do not assume all anterior chest wall pain is benign costochondritis—infectious costochondritis with osteomyelitis can occur and requires surgical debridement 5