In a typical adult with mild‑to‑moderate carpal tunnel syndrome and no contraindications (no active peptic ulcer disease, severe renal impairment, uncontrolled hypertension, or anticoagulant use), which over‑the‑counter NSAIDs are appropriate for PRN use?

NSAID Selection for Carpal Tunnel Syndrome

For a typical adult with mild-to-moderate carpal tunnel syndrome and no contraindications, NSAIDs are NOT recommended as effective therapy—neither for PRN use nor scheduled dosing. 1, 2, 3

Evidence Against NSAID Efficacy in CTS

The evidence consistently demonstrates that NSAIDs do not provide meaningful benefit for carpal tunnel syndrome:

• A prospective, randomized, double-blind, placebo-controlled trial found no significant reduction in symptom scores with NSAIDs (tenoxicam 20 mg daily) compared to placebo at 2 or 4 weeks in patients with mild-to-moderate CTS. 3

• Multiple systematic reviews and clinical guidelines confirm that over-the-counter analgesics, including both NSAIDs and acetaminophen, have not shown benefit for CTS symptoms. 2, 4

• The American Family Physician evidence reviews explicitly state that nonsteroidal anti-inflammatory drugs are not effective therapies for carpal tunnel syndrome. 1

Recommended First-Line Conservative Treatments

Instead of NSAIDs, the evidence supports these interventions for mild-to-moderate CTS:

Splinting (Most Accessible Option)

• Night-only neutral wrist splinting is as effective as continuous wear and should be the initial conservative approach. 2
• A neutral wrist position splint may be more effective than an extension splint. 2

Local Corticosteroid Injection (Most Effective Pharmacologic Option)

• Corticosteroid injection into the carpal tunnel provides significantly greater symptom relief than placebo, with mean symptom scores decreasing from 27.9 ± 6.9 to 10 ± 7.4 at 4 weeks. 3
• In patients with recent-onset CTS, corticosteroid injections provide slightly greater improvement at 6 weeks compared to splinting, with similar outcomes at 6 months. 2
• Local injection can provide relief for more than one month and delay the need for surgery at one year. 1

Oral Corticosteroids (Alternative When Injection Not Feasible)

• Oral prednisolone (20 mg daily for 2 weeks, then 10 mg daily for 2 weeks) demonstrated significant symptom reduction in controlled trials, unlike NSAIDs or diuretics. 3

Ineffective Therapies to Avoid

Do not prescribe these medications for CTS, as they lack evidence of benefit:

• NSAIDs (including ibuprofen, naproxen, diclofenac) 1, 2, 3
• Acetaminophen 2
• Diuretics 1, 3
• Vitamin B6 (pyridoxine) 1

When to Escalate to Surgery

Patients with severe CTS (objective weakness, thenar atrophy, or sensory deficits) should be offered immediate surgical decompression rather than any conservative therapy. 2

For mild-to-moderate cases, if symptoms have not improved after 4–6 months of conservative therapy (splinting or corticosteroid injection), surgical decompression should be offered. 1

Clinical Algorithm

1. Confirm diagnosis clinically (pain/paresthesias in median nerve distribution, positive Phalen maneuver, median nerve compression test). 1

2. Assess severity:

   • Mild-to-moderate (no weakness/atrophy) → conservative treatment 1
   • Severe (weakness, thenar atrophy, sensory deficits) → immediate surgical referral 2

3. For mild-to-moderate CTS, initiate:

   • Night-only neutral wrist splinting as first-line 2
   • If inadequate response after 2–4 weeks, add local corticosteroid injection 2, 3

4. Reassess at 4–6 months:

   • Persistent symptoms → surgical decompression 1

Common Pitfall

The most common error is prescribing NSAIDs or acetaminophen for CTS based on general pain management principles, when high-quality evidence demonstrates these agents are ineffective for this specific condition. 1, 2, 3 CTS is a compressive neuropathy, not an inflammatory condition, which explains why anti-inflammatory medications do not address the underlying pathophysiology. 4