The Safety of Postoperative Selective Cyclooxygenase-2 Inhibitors in Chronically Anticoagulated Patients Undergoing Primary Total Hip Arthroplasty.

BACKGROUND: Nonsteroidal anti-inflammatory drugs (NSAIDs), particularly selective cyclooxygenase-2 (COX-2) inhibitors, are foundational to multimodal pain management following primary total-hip arthroplasty (THA) but concerns regarding bleeding often limit their use in patients receiving chronic anticoagulation. While data support COX-2 inhibitor safety following total knee arthroplasty in this population, THA-specific evidence remains limited. METHODS: Utilizing a national database, patients undergoing primary THA on chronic anticoagulation between 2015 and 2025 were identified and stratified by postoperative exposure to selective COX-2 inhibitors (celecoxib or meloxicam). Propensity-score matching, which included preoperative anemia and history of acute kidney injury as covariates, balanced demographic and clinical characteristics between groups. The primary outcomes were blood transfusion and readmission at cumulative 30, 90, and 180 days postoperatively. Secondary outcomes included reoperation, periprosthetic dislocation, deep vein thrombosis, pulmonary embolism, acute kidney injury, emergency department utilization, and cumulative opioid use through 180 days. RESULTS: The COX-2 inhibitor use was not associated with elevated rates of transfusion, inpatient readmission, reoperation, periprosthetic dislocation, deep vein thrombosis, acute kidney injury, or emergency department utilization at any timepoint (all P > 0.05). Pulmonary embolism was directionally lower in the COX-2 cohort, reaching nominal significance at 180 days (relative risk (RR) 0.46, P = 0.012). The COX-2 inhibitor recipients demonstrated lower cumulative opioid use at 30 days (9.84 versus 17.35%; RR:0.567, P < 0.001), 90 days (11.89 versus 18.78%; RR:0.633, P < 0.001), and 180 days (15.33 versus 21.88%; RR:0.701, P < 0.001) compared with patients not receiving COX-2 inhibitors. CONCLUSIONS: In chronically anticoagulated patients undergoing primary THA, postoperative COX-2 inhibitor use was not associated with increased bleeding, readmission, renal, or surgical complications and was associated with lower cumulative postoperative opioid utilization. These observational findings support cautious COX-2 inhibitor use within multimodal analgesia in this population; however, future prospective studies are warranted to validate these findings.