A study by the U.S. Department of Veterans Affairs could push Amgen Inc.'s Enbrel etanercept and other TNF alpha inhibitors back to third-line therapy for RA. More importantly, similar payer-backed studies testing cost-containment strategies in diseases dominated by expensive specialty drugs are likely to become the norm.

The VA-funded RACAT study focused on RA patients who had progressed on methotrexate. The results, released last month, showed it made no difference in key 48-week outcomes whether the next step was to add generic sulfasalazine and hydroxychloroquine or to add Enbrel.