Treatment algorithm

Please note that formulations/routes and doses may differ between drug names and brands, drug formularies, or locations. Treatment recommendations are specific to patient groups: see disclaimer

ACUTE

inflammatory

1st line – non-steroidal anti-inflammatory drugs (NSAIDs)

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ACUTE
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inflammatory
1st line – 

non-steroidal anti-inflammatory drugs (NSAIDs)

NSAIDs provide pain control and inhibit the theoretical inflammatory component in costochondritis.

In patients at high risk of gastrointestinal (GI) complications (e.g., history of GI bleeding, age >60 years, concomitant corticosteroid or anticoagulants), a COX-2 inhibitor (e.g., celecoxib) instead of a standard non-selective NSAID, and preventive measures such as prophylactic use of a proton-pump inhibitor (PPI), should be considered.[28][29][30]

COX-2 inhibitors confer a reduced risk of gastrointestinal toxicity compared with traditional non-selective NSAIDs, and co-prescription of PPIs can reduce the risk even further, especially if the patient is also on low-dose aspirin.[31] The choice of NSAID/COX-2 inhibitor should be adapted to the patient profile.[32]

Treatment is usually for 10 to 14 days.

Primary options

diclofenac potassium: 50 mg orally (immediate-release) three times daily when required

OR

ibuprofen: 400-800 mg orally every 6-8 hours when required, maximum 2400 mg/day

OR

naproxen: 250-500 mg orally twice daily when required, maximum 1250 mg/day

OR

meloxicam: 7.5 to 15 mg orally once daily when required

OR

celecoxib: 100-200 mg orally twice daily when required

Consider – proton-pump inhibitor

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ACUTE
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inflammatory
Consider – 

proton-pump inhibitor

Additional treatment recommended for SOME patients in selected patient group

In patients at high risk of gastrointestinal (GI) complications from NSAIDs (e.g., history of GI bleeding, age >60 years, concomitant corticosteroid or anticoagulants), preventive measures such as proton-pump inhibitors (PPIs) should be considered.[28][29][30] COX-2 inhibitors confer a reduced risk of gastrointestinal toxicity compared with traditional non-selective NSAIDs, and co-prescription of PPIs can reduce the risk even further, especially if the patient is also on low-dose aspirin.[31]

Primary options

omeprazole: 20 mg orally once daily

OR

esomeprazole: 40 mg orally once daily

OR

rabeprazole: 20 mg orally once daily

OR

pantoprazole: 40 mg orally once daily

OR

lansoprazole: 30 mg orally once daily

2nd line – intra-articular injection with corticosteroid plus local anaesthetic

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ACUTE
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inflammatory
2nd line – 

intra-articular injection with corticosteroid plus local anaesthetic

In patients unresponsive or intolerant to NSAIDs, local corticosteroid injection with anaesthetic (e.g., lidocaine 1%) acts as a potent anti-inflammatory agent and may provide pain relief.

Potential local complications include infection, self-limited bleeding, and, rarely, pneumothorax.

Usually performed by specialists (e.g., rheumatologist).

Primary options

methylprednisolone acetate: 10-20 mg intra-articularly as a single dose, refer to consultant for further guidance on dose

OR

lidocaine: (1% solution) 1 ml intra-articularly as a single dose

infective

1st line – surgical drainage and/or debridement

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ACUTE
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infective
1st line – 

surgical drainage and/or debridement

Surgical drainage and/or debridement with appropriate antibiotic cover and wound care is recommended.​[11]​

Early drainage plus intravenous antibiotics may be sufficient for the management of bacterial costochondritis in intravenous drug users.[33] Bacterial costochondritis complicating thoracic surgery generally requires debridement.[33]

Plus – antibiotics

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ACUTE
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infective
Plus – 

antibiotics

Treatment recommended for ALL patients in selected patient group

Appropriate coverage depends on the exact clinical scenario, local bacterial sensitivities, and culture results. Consult with the local microbiology service is advisable.

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Choose a patient group to see our recommendations

Please note that formulations/routes and doses may differ between drug names and brands, drug formularies, or locations. Treatment recommendations are specific to patient groups. See disclaimer

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