Moderate
Budesonide × Ketorolac
Inhaled corticosteroids (ICS)×Non-steroidal anti-inflammatory drugs (NSAIDs)
Mechanism
Glucocorticoid plus NSAID — additive risk of GI ulcers and bleeding. Systemic budesonide (Cortiment, Entocort) raises risk; inhaled budesonide does not.
Symptoms
Epigastric pain, heartburn, black or tarry stools, blood in vomit, bruising. Higher risk in older patients, prior peptic ulcer, and concurrent anticoagulants.
Management
Ketorolac is not prescribed with systemic budesonide — risk outweighs benefit. For acute pain: paracetamol up to 3 g/day or metamizole. If NSAIDs are necessary (short course in cancer or postoperative pain), add pantoprazole 20 mg/day and cap ketorolac at 5 days. Inhaled budesonide with NSAIDs is safe.