Simplifying care to close the gap: Rethinking treatment burden in diabetes and chronic disease

November was Diabetes Awareness Month, which often sparks predictable conversations about the rising prevalence of diabetes and its complications, the value of early detection in slowing progression, the role of patient lifestyle changes in managing the disease, and the healthcare inequities faced by different racial and ethnic groups and geographic locales. Of these, one of the most enduring and least examined sources of inequity is the burden of treatment borne by those with the fewest resources. For millions of people living with diabetes and other chronic conditions in underserved communities, the task of managing health extends far beyond the clinic.

Diabetes rarely occurs in isolation. Diabetes, chronic kidney disease (CKD), cardiovascular disease, neuropathy, and hypertension frequently intertwine, creating a tangled web requiring multiple prescriptions, varying dosing schedules, and complex monitoring, and resulting in side effects that affect patient quality of life. These layers of complexity disproportionately affect patient populations already facing structural barriers to care, including limited access to specialty healthcare providers, inconsistent insurance coverage, transportation constraints, and language and literacy challenges.

As a practicing physician, and now as a biotech founder, I’ve seen firsthand how treatment complexity itself becomes a form of inequity. The more complicated a treatment regimen is, the less likely it is to be followed by patients, and the worse the outcomes. Coming off the heels of a month that prompts disease awareness, it’s past time we expand the discussion to include something fundamental: simplifying the complexity of medical treatments extends beyond convenience to improving equity.

The hidden burden of treatment complexity

When clinicians talk about “adherence”, it often sounds like a simple matter of patient choice, but adherence is rarely just about compliance or willpower. Adherence is shaped by treatment design, the patient’s environment, and the practical feasibility of the treatment regimen.

Individuals managing diabetes alongside CKD or other chronic diseases may be asked to swallow upward of a dozen medications daily, sometimes as many as 20 to 30 pills per day depending on coexisting conditions, with each treatment having its own dosing frequency and instructions related to timing medications relative to meals. For many patients, especially those with limited resources, this creates an almost impossible balancing act, with variables to consider such as:

Managing medications while working multiple jobs
Storing and transporting pills without stable housing
Navigating instructions in a non-native language
Choosing which prescriptions to fill when co-pays stack up
Prioritising the treatment of certain symptoms over others because daily life leaves little room for nuance

Complexity magnifies existing health disparities. A study from 2021 found that patients from underserved backgrounds are more likely to experience complications, not because their disease is inherently more severe, but because their care is harder to manage. Every additional step in a treatment plan becomes another barrier to improving patient care.

When polypharmacy meets inequity

Polypharmacy, the simultaneous use of multiple medications, with its inherently higher risk of drug interactions, is one of the most significant and underappreciated risk factors in chronic disease management. A longitudinal study from 2024 reported that 65% of older adults with two or more chronic diseases do not take all of their medications as prescribed.

For example, patients with diabetes who also have CKD, in addition to medications for glycaemic control, may also be prescribed medications to manage blood pressure, fluid balance, bone health, cardiovascular protection, and more. The complexity of polypharmacy to simultaneously manage these conditions is extraordinarily high.

In communities with fewer medical resources, inconsistent follow-up, or limited health literacy, these issues compound. Even well-designed treatment regimens sometimes fail when they collide with real-world constraints. For many patients, the question is not “Will this treatment work?”; rather, “Can I realistically fit this into my life?”

Simplified treatment regimens with fewer pills, fewer doses, and fewer steps have been shown to significantly improve adherence, particularly in populations disproportionately affected by diabetes complications. Yet, the healthcare system often underestimates this impact. Innovation tends to chase clinical endpoints, rather than lived experience. We celebrate the discovery of a more potent molecule, but sometimes fail to ask whether patients can, or will, take it every single day.

The human factor: What we often miss in drug development

One of the biggest blind spots in healthcare is the belief that patients behave like the “average” clinical trial participant. Clinical trial environments are structured with patients being supported and highly monitored, and are conducted under conditions that rarely reflect the reality of a patient’s daily life in underserved communities.

Three gaps consistently emerge:

Trial populations do not reflect the communities most affected. People from minority backgrounds or low-income groups remain underrepresented in clinical research. This lack of diversity skews our understanding of how treatments perform across populations and masks practical barriers that affect real-world use.
Patient-reported outcomes are undervalued. We meticulously measure biochemical markers, but often pay less attention to patient feedback on attributes such as pill size, taste, dosing frequency, and gastrointestinal side effects. However, it is these seemingly minor factors that routinely determine whether a treatment regimen is sustainable over the long-term.
We design most treatments for biology, not behaviour. A treatment may be clinically effective, but behaviourally unrealistic. Simplifying pill burden, dosing schedules, or formulations can be as impactful as clinical potency. Together, these treatment simplifications can be the difference between patients adhering to therapy or quietly abandoning it.

Often, researchers are blindsided by the search for a cure-all. However, if we want to address inequity in diabetes and CKD care, we must design therapies that meet patients where they actually are, not where the system assumes they are. This patient-focused approach is what inspired Unicycive’s development of its main therapeutic, oxylanthanum carbonate (OLC), for example.

By thoroughly examining every step of a patient's chronic illness journey, treatment innovations, such as complementing everyday routines or switching to a more palatable flavour, can be life-changing and contribute to the development of a more caring and inclusive healthcare system.

Advancing toward bias-resistant, patient-centred innovation

Reducing treatment complexity is not just about convenience. Instead, we must view it through the lens of bias reduction. When therapies require intricate dosing, frequent follow-up, or high health literacy, they inadvertently favour patients with stable resources, strong support systems, and flexible work lives. Patients without these privileges face steeper odds.

Encouragingly, the medical field is beginning to shift, and across therapeutic areas we are seeing:

Formulations designed to reduce pill burden
Longer-acting treatments that reduce dosing frequency
Delivery methods that require less equipment or fewer clinic visits
Digital tools to support medication management and health literacy
Greater inclusion of patient-reported outcomes in trial design

These changes move us towards a more equitable system – one where innovation considers not only what is medically possible, but also what is practically achievable in the real-world clinical setting.

Reframing the diabetes conversation

Diabetes Awareness Month is an annual reminder of how far we have come and how far we still must go. Awareness without action is not enough. As a healthcare community, we must broaden our view of innovation to include simplicity, usability, and equity.

Reducing treatment burden may not make headlines the way the introduction of a novel drug class does, but, for millions of people managing diabetes alongside other chronic conditions, it is one of the most meaningful healthcare improvements that we can offer. The path to better outcomes is not just created by breakthroughs in the laboratory, but by whether patients can consistently and sustainably integrate new treatment regimens into their daily lives.

To begin to close the equity gap in diabetes, we must commit to designing therapies that account for the practical realities of the people we aim to serve. Simplification is not the final aim; it is the foundation upon which equitable healthcare can grow and flourish.

About the author

Shalabh Gupta, MD, is president & CEO of Unicycive Therapeutics, which he founded in 2016. He has expertise in biotech, medicine, and finance as a prior Wall Street advisor. He has founded two other biotech companies. Gupta earned his medical degree in India and completed his residency at NYU School of Medicine. He also holds an MPA in Health Care Finance & Management from NYU. Before entering biotech and finance he was an attending physician and clinical faculty member at NYU Medical Center.