diff --git a/changelog.d/17912.misc b/changelog.d/17912.misc
new file mode 100644
index 0000000000..f6f661476a
--- /dev/null
+++ b/changelog.d/17912.misc
@@ -0,0 +1 @@
+Add an index to `current_state_delta_stream` table.
diff --git a/synapse/storage/databases/main/state_deltas.py b/synapse/storage/databases/main/state_deltas.py
index ba52fff652..117ee89d0a 100644
--- a/synapse/storage/databases/main/state_deltas.py
+++ b/synapse/storage/databases/main/state_deltas.py
@@ -20,18 +20,26 @@
 #
 
 import logging
-from typing import List, Optional, Tuple
+from typing import TYPE_CHECKING, List, Optional, Tuple
 
 import attr
 
 from synapse.logging.opentracing import trace
 from synapse.storage._base import SQLBaseStore
-from synapse.storage.database import LoggingTransaction, make_in_list_sql_clause
+from synapse.storage.database import (
+    DatabasePool,
+    LoggingDatabaseConnection,
+    LoggingTransaction,
+    make_in_list_sql_clause,
+)
 from synapse.storage.databases.main.stream import _filter_results_by_stream
 from synapse.types import RoomStreamToken, StrCollection
 from synapse.util.caches.stream_change_cache import StreamChangeCache
 from synapse.util.iterutils import batch_iter
 
+if TYPE_CHECKING:
+    from synapse.server import HomeServer
+
 logger = logging.getLogger(__name__)
 
 
@@ -54,6 +62,21 @@ class StateDeltasStore(SQLBaseStore):
     # attribute. TODO: can we get static analysis to enforce this?
     _curr_state_delta_stream_cache: StreamChangeCache
 
+    def __init__(
+        self,
+        database: DatabasePool,
+        db_conn: LoggingDatabaseConnection,
+        hs: "HomeServer",
+    ):
+        super().__init__(database, db_conn, hs)
+
+        self.db_pool.updates.register_background_index_update(
+            update_name="current_state_delta_stream_room_index",
+            index_name="current_state_delta_stream_room_idx",
+            table="current_state_delta_stream",
+            columns=("room_id", "stream_id"),
+        )
+
     async def get_partial_current_state_deltas(
         self, prev_stream_id: int, max_stream_id: int
     ) -> Tuple[int, List[StateDelta]]:
diff --git a/synapse/storage/schema/main/delta/88/04_current_state_delta_index.sql b/synapse/storage/schema/main/delta/88/04_current_state_delta_index.sql
new file mode 100644
index 0000000000..ad54302a8f
--- /dev/null
+++ b/synapse/storage/schema/main/delta/88/04_current_state_delta_index.sql
@@ -0,0 +1,18 @@
+--
+-- This file is licensed under the Affero General Public License (AGPL) version 3.
+--
+-- Copyright (C) 2024 New Vector, Ltd
+--
+-- This program is free software: you can redistribute it and/or modify
+-- it under the terms of the GNU Affero General Public License as
+-- published by the Free Software Foundation, either version 3 of the
+-- License, or (at your option) any later version.
+--
+-- See the GNU Affero General Public License for more details:
+-- <https://www.gnu.org/licenses/agpl-3.0.html>.
+
+
+-- Add an index on (user_id, device_id, algorithm, ts_added_ms) on e2e_one_time_keys_json, so that OTKs can
+-- efficiently be issued in the same order they were uploaded.
+INSERT INTO background_updates (ordering, update_name, progress_json) VALUES
+    (8804, 'current_state_delta_stream_room_index', '{}');