Approach

The main goal of treatment is pain relief for inflammatory costochondritis; surgical debridement is the mainstay of treatment for infectious costochondritis.

Inflammatory

Initial treatment for all patients is an oral nonsteroidal anti-inflammatory drug (NSAID) for 10 to 14 days. 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 nonselective NSAID, and preventive measures such as prophylactic use of a proton-pump inhibitor (PPI) for the same time period, should be considered.[28][29][30]

COX-2 inhibitors confer a reduced risk of gastrointestinal toxicity compared with traditional 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]

A corticosteroid injection with local anesthetic into the affected costochondral joints should be given to patients who are unresponsive or intolerant to NSAIDs. This is usually performed by a specialist (e.g., rheumatologist).

A retrospective study suggested that corticosteroid injections and sulfasalazine could be helpful in the treatment of costochondritis.[3] However, the study was limited due to the small number of subjects, retrospective design, and the lack of control group. In addition, patients treated with sulfasalazine continued to receive corticosteroid injections, thereby limiting the effective evaluation of sulfasalazine.

If pain persists, the diagnosis should be reevaluated and referral to a rheumatologist considered.

Infectious

Antibiotics alone are usually ineffective because of the poor blood supply to cartilage, and surgical debridement and/or drainage (when such a collection exists and is amenable to aspiration) is the treatment of choice.[10][11][13][14] This should be done with appropriate antibiotic cover and wound care.

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] 

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