What is the best management plan for an elderly patient with stable anemia, leukopenia, and carpal tunnel syndrome, currently taking pregabalin and paracetamol, with a history of gastritis?

Management of Carpal Tunnel Syndrome Pain in an Elderly Patient with Gastritis

For this elderly patient with carpal tunnel syndrome and gastritis history, continue pregabalin 25mg twice daily and paracetamol PRN as planned, while strictly avoiding NSAIDs including Celebrex—this approach prioritizes safety over marginal efficacy gains, given that gabapentinoids show no proven benefit for carpal tunnel syndrome and NSAIDs pose unacceptable gastrointestinal and renal risks in elderly patients.

Pain Management Algorithm for Carpal Tunnel Syndrome

First-Line: Paracetamol (Acetaminophen)

• Paracetamol remains the safest first-line oral analgesic for elderly patients with musculoskeletal pain, with superior safety compared to NSAIDs and no gastrointestinal bleeding, renal toxicity, or cardiovascular risks 1
• Optimize to full therapeutic dosing: 1000mg per dose, up to 4000mg daily maximum, before considering any escalation 1
• Paracetamol demonstrates excellent cardiovascular and cerebrovascular safety with no reports of harm, unlike NSAIDs 2
• Continue paracetamol PRN as currently prescribed for this patient 1

Adjunctive Therapy: Pregabalin for Neuropathic Component

• The plan to increase pregabalin from 25mg nocte to 25mg twice daily is reasonable for neuropathic pain management, though evidence specifically for carpal tunnel syndrome is lacking 2
• Pregabalin dosing for neuropathic pain typically starts at 75mg twice daily, increasing after 4-7 days to a goal of 300mg/day as necessary up to 600mg/day 2
• However, a 2023 population study found gabapentinoids are frequently prescribed for CTS despite robust evidence recommending against their use, with no proven efficacy in randomized trials 3
• A randomized controlled trial of gabapentin (chemically similar to pregabalin) showed no significant reduction in carpal tunnel symptom severity compared to placebo over 8 weeks 4
• The current low dose (25mg BD) may provide modest benefit for sleep and pain without significant risk, but expectations should be tempered 5

Critical: NSAID Avoidance in This Patient

NSAIDs are contraindicated in this elderly patient with gastritis history:

• Active or previous gastritis represents a significant gastrointestinal risk factor requiring absolute NSAID avoidance 2, 1
• The American Geriatrics Society recommends NSAIDs should be avoided or used with extreme caution in older adults aged 70+ due to significant cardiovascular, renal, and gastrointestinal risks that outweigh benefits 6
• The relative risk of serious GI complications is 3- to 5-fold greater among NSAID users versus nonusers 1
• Celebrex (celecoxib) and other COX-2 inhibitors carry cardiovascular toxicity risks and should not be used when other therapeutic options provide acceptable pain relief 2, 7
• The plan to avoid anti-inflammatories due to previous gastritis is correct and should be maintained 1, 6

Why Opioids Were Appropriately Discontinued

• The decision to discontinue oxycodone after the 1-week emergency course is appropriate 7, 1
• Opioids should NOT be prescribed as first-line therapy for chronic pain in elderly patients due to increased risk of cognitive impairment, falls, respiratory depression, and addiction 1
• Elderly patients are at increased risk of opioid side effects including oversedation and respiratory depression 7
• Failure to respond to a time-limited opioid course (which this patient did respond to) should lead to reevaluation, but since pain is now controlled with brace and current regimen, continuation is unnecessary 7

Monitoring and Follow-Up Strategy

Pain Assessment

• Reassess pain control at each visit using specific metrics: ability to sleep, functional hand use, and pain interference with daily activities 2
• If pain remains uncontrolled despite optimized paracetamol and pregabalin, consider increasing pregabalin incrementally toward therapeutic doses (150-300mg daily in divided doses) rather than adding NSAIDs 2, 5

Medication Safety Monitoring

• Monitor for pregabalin adverse effects: dizziness (23.1% incidence), drowsiness (14.6%), and peripheral edema (10.4%), which are dose-dependent and manageable with dose reduction 5
• Assess renal function given the patient's leukopenia workup—pregabalin requires dose adjustment in kidney insufficiency 2
• Watch for psychiatric effects or euphoria risk, particularly given pregabalin's abuse potential 2

Surgical Planning Considerations

• The patient is appropriately awaiting orthopaedic surgery, which is superior to conservative therapies for persistently symptomatic carpal tunnel syndrome 8
• Continue current conservative management (wrist brace, physiotherapy, optimized analgesia) as a bridge to definitive surgical treatment 8
• The 2-month waiting period is acceptable given current pain control with non-pharmacological measures 8

Common Pitfalls to Avoid

1. Do not add NSAIDs despite inadequate pain relief—the gastritis history and elderly age create unacceptable risk, and topical NSAIDs would be the only consideration if absolutely necessary 2, 1, 6

2. Do not expect dramatic improvement from pregabalin dose escalation—evidence shows gabapentinoids lack efficacy specifically for carpal tunnel syndrome, unlike their proven benefit in other neuropathic conditions 4, 3

3. Do not restart opioids for chronic management—reserve only for severe, disabling pain uncontrolled by all other measures, and only as a bridge to surgery 7, 1

4. Do not prescribe muscle relaxants or benzodiazepines—these carry high sedation risk, confusion, and falls in elderly patients with minimal evidence for chronic pain 1