RACAT is a double-blind, non-inferiority trial of 353 patients who were randomized to etanercept plus methotrexate or a triple regimen consisting of methotrexate, hydroxychloroquine and sulfasalazine. After 24 weeks of treatment, patients not achieving a DAS improvement of 1.2 were switched in a blinded fashion to the other therapy.
Cost analyses were performed using Quality Adjusted Life Years (QALYs). These were estimated every 24 weeks utilizing US societal values from the EQ-5D instrument. Incremental cost-effectiveness ratios were calculated assuming intention-to-treat and presented during this plenary session.
Results showed that etanercept offered only marginally more accumulated QALYs over triple therapy, but with greater accumulation of drug costs. This translated to incremental cost-effectiveness ratios for etanerecept vs. triple therapy of $2.7 million/QALY gained over 24 weeks and $0.95 million/QALY over 48 weeks.
The large additional cost of etanercept provided very small benefits over triple therapy. It was only cost effective only after triple therapy failure. Controversially (but appropriately?), the authors commented that if triple therapy was used first, billions of dollars could be saved. This money coud be used to further improve health outcomes using other intervention strategies.