What is the treatment for Polyarteritis nodosa (PAN) in the setting of acute Hepatitis B (HBV) infection?

From the Guidelines

For polyarteritis nodosa (PAN) associated with acute hepatitis B infection, the recommended treatment is a combination of antiviral therapy and immunosuppression, as suggested by the most recent guidelines 1. The treatment approach should prioritize controlling both the vasculitis and viral replication.

• Start with antiviral therapy using entecavir 0.5 mg orally daily or tenofovir 300 mg orally daily for hepatitis B, as these are preferred medications due to their higher potency and high viral resistance barrier 1.
• Concurrently, initiate glucocorticoid therapy with prednisone 1 mg/kg/day orally (maximum 60-80 mg/day) for 4 weeks, followed by a gradual taper over 4-6 months, as recommended for the management of vasculitis 1.
• Add plasmapheresis, 3-5 exchanges over 5-7 days, in severe cases, as suggested by the guidelines for hepatitis B-associated PAN 1.
• Once viral load begins to decrease, typically after 2-4 weeks of antiviral therapy, introduce immunosuppressive therapy, such as cyclophosphamide, at 2 mg/kg/day orally or 15 mg/kg IV pulse every 2-3 weeks for 3-6 months, as recommended for the treatment of PAN 1.
• Monitor hepatitis B viral load, liver function tests, and clinical symptoms of vasculitis regularly, and adjust immunosuppression based on disease activity and viral suppression, as suggested by the guidelines for the management of hepatitis B infection 1 and vasculitis 1. Key considerations in the treatment of PAN associated with acute hepatitis B infection include:
• The use of antiviral therapy to prevent viral reactivation during immunosuppression 1
• The potential risks and benefits of immunosuppressive therapy, including the risk of bladder cancer associated with cyclophosphamide use 1
• The importance of regular monitoring and adjustment of treatment based on disease activity and viral suppression 1

From the Research

Treatment Options for Polyarteritis Nodosa (PAN) in the Setting of Acute Hepatitis B (HBV) Infection

• The treatment for PAN in the setting of acute HBV infection typically involves a combination of immunosuppressive agents, antiviral medications, and plasma exchanges 2, 3, 4, 5, 6.
• Immunossuppressive agents such as prednisone and cyclophosphamide may be used to reduce inflammation, but they can also stimulate viral replication 3, 5.
• Antiviral medications like lamivudine and vidarabine can help suppress viral replication and induce HBeAg seroconversion 2, 3, 4, 5, 6.
• Plasma exchanges can help reduce the level of circulating immune complexes 3, 4, 5, 6.
• Interferon-alpha2b has also been used in the treatment of HBV-related PAN, but it may not be effective in all cases 4.

Treatment Protocols

• A protocol consisting of short-term steroid therapy, antiviral agents, and plasma exchanges has been proposed as the first-line treatment for HBV-related PAN 3, 5, 6.
• The use of lamivudine, corticosteroids, and plasma exchanges has been reported to be effective in treating HBV-related PAN 2, 4, 6.
• The choice of treatment protocol may depend on the individual patient's circumstances and the availability of adequate follow-up 6.

Outcome and Prognosis

• The outcome of patients with HBV-related PAN can be good if treated promptly and effectively 3, 5, 6.
• HBeAg seroconversion and recovery from PAN can be achieved in a significant proportion of patients 3, 5.
• However, some patients may experience persistent HBV infection or relapse, and a small number may die from complications related to PAN or HBV infection 3, 5.