Transcutaneous Vagus Nerve Stimulation for the Treatment of Lupus

Patients with SLE and active, non-organ-threatening disease are eligible to participate in
this prospective randomized double blind trial of active or sham transcutaneous electrical
vagus nerve stimulation (tVNS). Active tNVS is performed by the use of a transcutaneous
electrical nerve stimulation (TENS) device with electrodes attached to an area of the
external ear innervated by the auricular branch of the vagus nerve. The same protocol is
followed in the sham tVNS arm, but the pads are placed on an area of the external ear that is
devoid of vagus innervation.TENS is applied for 60 to 120 minutes daily as tolerated and
participants keep a detailed log of their daily TENS sessions. Patients return to clinic at
weeks 4, 8 and 12 for study related assessments.

Inclusion Criteria:

1. Patients with SLE age 18-70 meeting the American College of Rheumatology
Classification Criteria. Patients need to meet a minimum of 4 out of 11 criteria
simultaneously or serially on two separate occasions.

2. Positive antinuclear antibody or anti-dsDNA within one year of screening

3. Non-serological SLEDAI ≥4 or ≥1 BILAG B or A and presence of inflammatory arthritis
(defined by at least 3 swollen and 3 tender joints) at screening

4. Patients may receive on one or more of the following immune suppressive therapies:
hydroxychloroquine, quinacrine, methotrexate, azathioprine, mycophenolate mofetil,
tacrolimus, sirolimus, belimumab, abatacept. Immune suppressive medications should
have been administered at stable doses for ≥30 days prior to baseline. Patients may
also be on prednisone up to 10mg daily or equivalent steroid treatment at the baseline
visit.

Exclusion Criteria:

1. Acute lupus nephritis defined as class II,III, IV or V nephritis diagnosed within 6
months or prot/creat > 1.5 gm/gm due to active lupus or in process of receiving
induction therapy for nephritis

2. Active CNS lupus affecting mental status

3. Any other organ threatening or life threatening manifestation of SLE as well as those,
who, in the opinion of the investigator, have severe multi-organ or refractory lupus

4. Rituximab treatment within 6 months prior to screening and/or without return of B
cells to baseline levels

5. Treatment with cyclophosphamide within a month prior to screening

6. Treatment with any investigational drug within 3 months or 5 half-lives whichever is
longer

7. Recurrent vaso-vagal syncopal episodes

8. Unilateral or bilateral vagotomy

9. Presence of any evidence of vagus nerve pathology or injury

10. Heart failure (NYHA class III or IV)

11. Known atherosclerotic disease, including severe carotid artery disease, uncontrolled
hypertension, uncontrolled diabetes, and history of myocardial infarction (MI),
cardiomyopathy or stroke within the past year. Clinically stable patients with
coronary artery disease, but no recent MI (within the past year) and no current
symptoms of angina are not however excluded.

12. Valvular and other structural heart disease that is evident by transthoracic
echocardiogram and is associated with heart failure (NYHA class III or IV)

13. Prolonged QT interval or abnormal baseline ECG - sick sinus syndrome, Mobitz type 2
second or third degree heart block, atrial fibrillation, atrial flutter, recent
history of ventricular tachycardia or ventricular fibrillation or clinically
significant premature ventricular contraction

14. Individuals currently implanted with an electrical and/or neurostimulator device, such
as cardiac pacemaker or defibrillator, vagal neurostimulator, deep brain stimulator,
spinal stimulator, bone growth stimulator, or cochlear implant

15. Known respiratory disease that has decreased any pulmonary function test more than 25%
below expected values or has resulted in hospitalization within the past year

16. All diagnosed syndromes affecting the central nervous system (CNS) or autonomic
nervous system

17. Major psychiatric disorders including evidence of major depressive disorder (DSM-5
diagnostic criteria) that is not currently controlled by medications

18. Hemoglobin below 9.0 gm/dL (by the most recent CBC)

19. Pregnancy or breast feeding

20. Inability or unwillingness to understand and/or sign informed consent

21. Any other medical condition, whether or not related to lupus, which, in the opinion of
the investigator, would render the patient inappropriate or too unstable to complete
the study protocol