Moderate
Budesonide × Diclofenac
Inhaled corticosteroids (ICS)×Non-steroidal anti-inflammatory drugs (NSAIDs)
Mechanism
Glucocorticoid plus NSAID — additive GI ulcer and bleeding risk with systemic budesonide. Inhaled budesonide does not clinically affect risk.
Symptoms
Epigastric pain, heartburn, black or tarry stools, blood in vomit, bruising. Higher risk in older patients, prior peptic ulcer, and concurrent anticoagulants.
Management
On systemic budesonide, limit diclofenac to short courses (no more than 5–7 days) with pantoprazole 20 mg/day. For long-term analgesia: paracetamol up to 2 g/day or topical NSAIDs. Inhaled budesonide with diclofenac is safe. In older patients and prior peptic ulcer, risk outweighs benefit.