Bayesian Approaches for Confirmatory Trials in Rare Diseases: Opportunities and Challenges.

The aim of this narrative review is to introduce the reader to Bayesian methods that, in our opinion, appear to be the most important in the context of rare diseases. A disease is defined as rare depending on the prevalence of the affected patients in the considered population, for example, about 1 in 1500 people in U.S.; about 1 in 2500 people in Japan; and fewer than 1 in 2000 people in Europe. There are between 6000 and 8000 rare diseases and the main issue in drug development is linked to the challenge of achieving robust evidence from clinical trials in small populations. A better use of all available information can help the development process and Bayesian statistics can provide a solid framework at the design stage, during the conduct of the trial, and at the analysis stage. The focus of this manuscript is to provide a review of Bayesian methods for sample size computation or reassessment during phase II or phase III trial, for response adaptive randomization and of for meta-analysis in rare disease. Challenges regarding prior distribution choice, computational burden and dissemination are also discussed.