Treatment of Costochondritis

First-Line Pharmacological Management

NSAIDs at maximum tolerated and approved dosage should be initiated as first-line treatment for costochondritis. 1

Naproxen 375–1100 mg per day in two divided doses is recommended for active costochondritis 1
Ibuprofen 1800 mg per day in divided doses is an alternative first-line option 1
Diclofenac should be started at 150 mg per day, with maintenance dosing of 75–100 mg per day 1
Use oral NSAIDs at the lowest effective dose for the shortest possible period to minimize systemic risks 1
Evaluate treatment response after 2-4 weeks to determine if therapy modification is needed 1

For patients with increased gastrointestinal risk factors, celecoxib 200–400 mg per day should be prescribed 1
Patients with gastrointestinal risk should receive non-selective NSAIDs plus a gastroprotective agent (proton pump inhibitor), or a selective COX-2 inhibitor 1
Avoid NSAIDs entirely in patients with active peptic ulcer disease, severe renal impairment, or recent cardiovascular events due to increased risk of gastrointestinal, renal, and cardiovascular toxicity 1
Monitor for gastrointestinal, liver, and cardiorenal toxicity with prolonged NSAID use, particularly in elderly patients and those with comorbidities 1

Regular dosing of acetaminophen (paracetamol) may be needed as an alternative or adjunct when NSAIDs are insufficient, contraindicated, or poorly tolerated 1
If inadequate response after 2-4 weeks, consider switching to a different NSAID or adding acetaminophen 1

Local corticosteroid injections directed to the specific costochondral junction may be considered for persistent focal pain despite adequate NSAID therapy 1
Short courses of oral prednisolone or intra-articular glucocorticoid injections may be considered as bridging options while awaiting the effect of other agents 1
Avoid long-term use of systemic glucocorticoids due to lack of evidence supporting their use for axial pain and significant adverse effect profile 1

Apply local heat or cold applications to the affected area 1
Regular stretching exercises should be implemented, as they have demonstrated progressive significant improvement in pain compared to control groups (p<0.001) 2
Physical therapy and osteopathic manipulation techniques may be useful, particularly in atypical costochondritis that does not self-resolve 3
Provide patient education about the condition and advise temporary rest of the affected area during the acute phase 1

Rule out serious cardiac causes before diagnosing costochondritis, especially in patients older than 35 years, those with cardiac risk factors, or any patient with cardiopulmonary symptoms—these patients require electrocardiogram and possibly chest radiograph 4
Coronary artery disease is present in 3-6% of adult patients with chest pain and chest wall tenderness to palpation 4
Do not use long-term systemic corticosteroids, which lack evidence and carry significant adverse effects 1
Distinguish infectious costochondritis (which requires antibiotics and possible debridement) from typical inflammatory costochondritis—infectious cases typically present with purulent drainage, systemic signs, or failure to respond to standard anti-inflammatory treatment 5