How would you manage a patient with severe deforming seronegative RA who has failed or been intolerant to DMARDs, TNFi, abatacept, Jak inhibitors, IL-6 and IL-1 agents in addition to Rituxan and moderate dose prednisone?  

I would potentially be referring such a patient for implantable vagal nerve stimulation when the device is available (potentially later this year). Importantly, in the RESET RA trial, patients with multiple drug failures tended to do better than “easier to control” RA.