What is the recommended treatment for an adult with post‑COVID‑19 neuropathic pain or nerve irritation?

Treatment of Post-COVID-19 Neuropathic Pain

NSAIDs should be initiated as first-line therapy for COVID-19-related neuropathic pain, with telemedicine as the primary delivery method for evaluation and ongoing management. 1

First-Line Pharmacological Management

• Start NSAIDs as the primary pharmacological intervention, monitoring carefully for gastrointestinal and renal adverse effects 1, 2
• Patients must report any new fever or worsening muscle pain immediately, as NSAIDs may mask early symptoms of disease progression 1
• Avoid opioids as initial therapy due to their immunosuppressive effects, which increase susceptibility to COVID-19 infection and worsen outcomes 1
• If opioids become absolutely necessary despite initial management failure, buprenorphine appears safest in immunocompromised patients 1

Corticosteroid Considerations

• Exercise extreme caution with corticosteroids for neuropathic pain management, as they cause immune suppression and increase viral infection risk 1, 2
• If steroids are deemed unavoidable, use the lowest effective dose with preference for dexamethasone or betamethasone over methylprednisolone 1, 2
• Steroid injections may increase the risk of viral infections and should be used with particular caution 2
• Any new steroid therapy that may influence COVID-19 disease course should be discussed with the treating infectious disease physician 3

Telemedicine-First Strategy

• Initiate all pain management through virtual consultations to evaluate, triage, and manage neuropathic pain while minimizing COVID-19 exposure risk 1, 2
• Telemedicine platforms facilitate multidisciplinary pain management and provide continuity of care 1
• Establish regular telemedicine check-ins to assess pain control, medication adverse effects, and functional status 1

Indications for In-Person Evaluation

Reserve face-to-face assessment for specific urgent scenarios 1, 2:

• Significant functional decline despite initial management
• Intractable pain unresponsive to NSAIDs and telemedicine-guided therapy
• Signs suggesting complex regional pain syndrome development
• Suspected Guillain-Barré syndrome or other acute neurological complications requiring immediate attention 1

Screen all patients for COVID-19 symptoms before any in-person visits 2

Non-Pharmacological Management

• Implement carefully paced physical activity programs, avoiding aggressive exercise which worsens symptoms in 75% of patients with post-exertional malaise 1, 2
• Use pacing strategies to prevent post-exertional symptom exacerbation 1
• Consider online self-management programs integrating exercise, sleep hygiene, and healthy lifestyle modifications 1
• Aggressive exercise or rehabilitation programs without careful pacing strategies should be avoided entirely 2

Critical Pitfalls to Avoid

• Never use hydroxychloroquine for COVID-19-related pain or infection, as it provides no benefit and may worsen prognosis 1
• Avoid routine opioid escalation given immunosuppressive effects 1
• Do not recommend aggressive exercise programs as they may worsen symptoms in patients with post-exertional malaise 2

Understanding the Pain Phenotype

Post-COVID pain can manifest as neuropathic (damage to somatosensory nervous system), nociceptive (tissue damage), nociplastic (altered pain processing without clear tissue damage), or mixed type 4. Neuropathic pain prevalence in COVID-19 survivors is estimated at 24.4%, with headache during acute COVID-19 increasing the odds of developing neuropathic pain by 4.9 times 5. One in six subjects will develop new-onset pain persisting beyond the acute phase 5.