What is the appropriate treatment for costochondritis?

Treatment for Costochondritis

Start with NSAIDs at maximum tolerated dosage as first-line therapy, evaluating response after 2-4 weeks, and reserve local corticosteroid injections for persistent focal pain that fails to respond to adequate NSAID therapy. 1

First-Line Pharmacological Management

The cornerstone of costochondritis treatment is NSAID therapy, with specific dosing recommendations based on guideline evidence:

• Naproxen 375-1100 mg daily in two divided doses 1
• Ibuprofen 1800 mg daily in divided doses 1
• Diclofenac starting at 150 mg daily, with maintenance dosing of 75-100 mg daily 1
• Celecoxib 200-400 mg daily for patients with gastrointestinal risk factors 1

Use oral NSAIDs at the lowest effective dose for the shortest possible period to minimize systemic risks, and consider topical NSAIDs to reduce systemic side effects. 1

Alternative and Adjunctive Pharmacological Options

When NSAIDs are insufficient, contraindicated, or poorly tolerated:

• Regular dosing of acetaminophen (paracetamol) may be needed as an alternative or adjunct for pain relief. 1
• For patients with increased gastrointestinal risk, use non-selective NSAIDs plus a gastroprotective agent, or a selective COX-2 inhibitor (which reduces serious GI risk with RR 0.18,95% CI: 0.14-0.23). 1

Second-Line Interventions for Refractory Cases

If inadequate response occurs after 2-4 weeks of NSAID therapy:

• 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 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

Non-Pharmacological Interventions

These should be integrated into the treatment plan from the outset:

• Apply local heat or cold applications to the affected area. 1
• Regular exercise and physical therapy should be considered as part of comprehensive treatment. 1
• Provide patient education about the condition and lifestyle recommendations. 1
• Temporary rest of the affected area during the acute phase is recommended. 1

Physical therapy utilizing manual therapy and therapeutic exercise targeting the cervicothoracic spine and ribcage may facilitate resolution, particularly in cases lasting several months. 2

Critical Safety Considerations and Contraindications

Before initiating NSAID therapy, identify absolute contraindications:

• Patients with active peptic ulcer disease, severe renal impairment, or recent cardiovascular events should avoid NSAID therapy 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

Common Pitfalls to Avoid

• Do not use long-term systemic corticosteroids, which lack evidence and carry significant adverse effects. 1
• Rule out serious causes of chest pain before diagnosing costochondritis, as it is often a diagnosis of exclusion—coronary artery disease is present in 3-6% of adult patients with chest pain and chest wall tenderness. 3
• Consider infectious costochondritis in patients with diabetes, immunosuppression, or signs of systemic infection, as this requires debridement and antimicrobial therapy rather than NSAIDs alone. 4