September 2026

RHEUMATOLOGY

VAGUS NERVE STIMULATION FOR RHEUMATOID ARTHRITIS IN PRACTICE: Q&A WITH ERIC RUDERMAN, MD

Key Takeaways
  • The FDA-approved indication for vagus nerve stimulation (VNS) is for adults with moderate-to-severe RA who have had an inadequate response to, or cannot tolerate, biologic or targeted synthetic DMARDs.
  • The ideal patient population and the best place in the treatment algorithm is unclear.
  • The therapy may be used with conventional or advanced RA medications, but the best combinations are unknown.
  • Implementation requires coordination between rheumatology and neurosurgery, followed by device programming and monitoring in rheumatology.
 
Who may be an appropriate candidate?
That's one of the biggest unanswered questions. The pivotal RESET-RA trial enrolled patients with active RA who had previously used advanced therapies, but we still do not know whether disease duration, prior treatment exposure or other patient characteristics predict response. The clinical sweet spot remains undefined.
 
Could it be an option for patients who cannot take biologics?
Potentially. One area of interest is patients who are unable or unwilling to take biologic therapies. However, the trial did not specifically answer that question, including for patients with chronic infections or other reasons advanced therapies may not be appropriate. That possibility should therefore be approached cautiously.
 
Can it replace medication?
Not necessarily. During the randomized phase, participants remained on conventional DMARDs but had washed out biologic and targeted synthetic therapies. After three months, participants could add advanced therapies. The device may function alone for some patients or as part of a broader treatment strategy, but we do not yet know which combinations may work best.
 
What does the care pathway look like?
Rheumatology evaluates whether the therapy is appropriate based on disease activity, treatment history and clinical goals. A neurosurgeon then evaluates the patient and performs implantation. After surgical follow-up and healing, programming, monitoring and long-term disease management return to the rheumatology team.
 
What are the practical considerations?
Programs need processes for patient selection, surgical coordination, device programming, follow-up and monitoring. A centralized model may be more practical than expecting every rheumatologist to manage a small number of devices independently.
 
What is the most important question moving forward?
Where does this belong in RA care? The trial showed that neuroimmune modulation can affect disease activity.
 
What we still need to understand is which patients are most likely to benefit, whether it is best used alone or in combination, and how it should be integrated into existing treatment strategies.
 
What is the takeaway for rheumatologists?
Neural signaling represents another way to influence inflammatory disease. VNS is an early clinical example of that concept. Whether this particular device becomes widely used remains to be seen, but neuroimmune modulation has created a new line of investigation for the field.
Eric M. Ruderman, MD, Professor of Rheumatology at Northwestern Medicine​

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