Dynamic enrichment of Bayesian small‐sample, sequential, multiple assignment randomized trial design using natural history data: a case study from Duchenne muscular dystrophy

In Duchenne muscular dystrophy (DMD) and other rare diseases, recruiting patients into clinical trials is challenging. Additionally, assigning patients to long‐term, multi‐year placebo arms raises ethical and trial retention concerns. This poses a significant challenge to the traditional sequential drug development paradigm. In this paper, we propose a small‐sample, sequential, multiple assignment, randomized trial (snSMART) design that combines dose selection and confirmatory assessment into a single trial. This multi‐stage design evaluates the effects of multiple doses of a promising drug and re‐randomizes patients to appropriate dose levels based on their Stage 1 dose and response. Our proposed approach increases the efficiency of treatment effect estimates by (i) enriching the placebo arm with external control data, and (ii) using data from all stages. Data from external control and different stages are combined using a robust meta‐analytic combined (MAC) approach to consider the various sources of heterogeneity and potential selection bias. We reanalyze data from a DMD trial using the proposed method and external control data from the Duchenne Natural History Study (DNHS). Our method's estimators show improved efficiency compared to the original trial. Also, the robust MAC‐snSMART method most often provides more accurate estimators than the traditional analytic method. Overall, the proposed methodology provides a promising candidate for efficient drug development in DMD and other rare diseases.