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INTRODUCTION

Worldwide, musculo-skeletal conditions are the most common cause of severe long-term pain and physical disability.1 Osteoarthritis is one such form of chronic degenerative joint disease.2 The etiological factor includes articular cartilage degeneration that presents clinically in the form of gradual development of joint pain, swelling, instability, stiffness and loss of movement.3

Approximately 50 million population has real joint disease and among them osteoarthritis is the commonest disease that is emerging as a major health and economical burden on the society.4 Its prevalence has increased in the past 2 to 3 decades because of increased life expectancy due to better living conditions and health facilities in India. The reported prevalence of osteoarthritis in India is 22% to 39 % that accounts for 30% of all rheumatological problems.5 There is a strong correlation between the prevalence of osteoarthritis and age. Radiological evidence of OA occurs in the majority of people by 65 years of age and in about 80% of those aged over 75 years. Osteoarthritis is more common in women than men but the prevalence increases dramatically with age as a consequence of menopausal changes (primarily as a loss of estrogen) in women. Above 65 years of age, 45% women have clinical symptoms where as

radiological evidence of OA has been found in 70% of women.6 In comparison to western population, the Indians have a high incidence of OA of knee joint while involvement of hip joint is less common in India.7 In our society, high involvement of knee joint is because of social habits of using Indian toilet seats, squatting and sitting cross-legged. Many factors like age of the patient, co-morbidities, clinical severity of osteoarthritis, cost factors, individual doctors or patient preference play a vital role in treatment

The main objectives for management of osteoarthritis are the reduction of pain with improvement in the functional status of the joint and to limit the progression of pathological changes to either delay or minimize the risk of arthroplasty.8 The management of OA includes non-pharmacological

measures,

pharmacological

therapy

and

rehabilitational therapy and surgical procedures.

Non-pharmacological non-surgical therapy for osteoarthritis is in the form of patient education, weight loss, physical therapy, occupational therapy, reorientation of living style and has been tried with some success.

Currently symptomatic relief is provided by the use of nonsteroidal anti-inflammatory drugs (NSAIDs) but they do not reverse and may accelerate the basic pathology of disease like degeneration of

cartilage, inhibit chondroitin synthesis and suppress proteoglycans

synthesis by the chondrocyte.9,10

Attempts have been made in combining NSAIDs with other groups of

drugs having analgesic activity. Opioid analgesic agents have been

combined with NSAIDs in order to achieve an effective degree of analgesia but the undesirable part of this combination is addictive properties of opioids and their usefulness is only for a short span of time.11

Combining paracetamol with traditional nonsteroidal anti- inflammatory drugs (NSAIDs) for short courses is useful in OA without an increase in side effects but over long term, increased risk of upper GIT bleed has been observed than that conferred by NSAID alone.12,13,14

The above said combinations, though provide symptomatic relief, yet are unable to prevent or limit further progression or worsening of the disease. Thus there is an urgent need to find a drug which can modify the disease process in addition to its analgesic activity.

The drugs that modify the disease progression are classified as symptomatic slow acting drugs in osteoarthritis (SYSDOA). They have a slow onset of efficacy with a long carry over effect after the treatment is withdrawn.15 Glucosamine, chondriotin sulphate and Diacerein8 are the available options that can be combined with NSAIDs as add on therapy3