Is celecoxib (Celebrex) use a risk factor for bleeding in patients undergoing cervical epidural steroid injections (ESI)?

Celecoxib Use and Bleeding Risk in Cervical Epidural Steroid Injections

Celecoxib use does not appear to be a significant risk factor for bleeding complications during cervical epidural steroid injections (ESI), based on the available evidence showing NSAIDs including COX-2 inhibitors can be safely continued during these procedures.

Evidence Supporting Safety of Celecoxib During Cervical ESI

The most recent and directly relevant study demonstrates the safety profile of continuing anticoagulation and NSAIDs during cervical procedures:

• A 2025 retrospective review of 2,792 cervical transforaminal ESIs found zero cases of symptomatic epidural hematomas or bleeding complications in 763 procedures performed on patients taking NSAIDs 1
• This study specifically evaluated the safety of continuing NSAIDs (which would include celecoxib) during cervical ESI procedures 1

Historical Safety Data from Epidural Procedures

Earlier prospective evidence supports this finding:

• A prospective study of 1,214 epidural steroid injections found that NSAIDs did not increase the frequency of minor hemorrhagic complications (blood noted during needle placement occurred in 5.2% overall, with no difference in NSAID users) 2
• There were zero spinal hematomas (major hemorrhagic complications) in this cohort, despite 32% of patients taking NSAIDs 2

Celecoxib-Specific Bleeding Risk Profile

While celecoxib has lower GI bleeding risk than nonselective NSAIDs, it still carries some hemorrhagic considerations:

• The FDA label warns that celecoxib may increase bleeding risk, particularly when combined with anticoagulants, antiplatelet drugs, SSRIs, or SNRIs 3
• However, this bleeding risk is primarily gastrointestinal rather than related to procedural bleeding 4

Risk Factors That Actually Matter for Cervical ESI Bleeding

The 2024 large database study of 448,209 cervical ESIs identified the true risk factors for complications:

• Anticoagulant prescription was associated with 5.40-fold increased odds of complications within 30 days 5
• Antiplatelet medication prescription (aspirin, clopidogrel) was associated with 2.21-fold increased odds of procedural complications at 7 days 5
• Transforaminal approach had 1.55-fold higher odds of procedural complications compared to interlaminar approach 5
• NSAIDs were not identified as independent risk factors in this comprehensive analysis 5

Critical Distinction: Anticoagulants vs NSAIDs

The evidence clearly differentiates between true anticoagulants and NSAIDs:

• One case report documented epidural hematoma after cervical ESI in a patient on warfarin and enoxaparin, despite following anticoagulation guidelines 6
• This occurred with therapeutic anticoagulation, not NSAID use 6

Clinical Pitfalls to Avoid

• Do not confuse celecoxib (a COX-2 inhibitor NSAID) with true anticoagulants like warfarin or direct oral anticoagulants - the bleeding risk profiles are fundamentally different 5
• Do not unnecessarily discontinue celecoxib before cervical ESI - this may worsen pain control without meaningful safety benefit 1, 2
• Be aware that combining celecoxib with aspirin or anticoagulants does increase bleeding risk - monitor these patients more carefully 3

Monitoring Recommendations

If proceeding with cervical ESI in patients on celecoxib:

• Monitor for signs of bleeding complications in the immediate post-procedural period and up to 1 week following the procedure 1
• Consider additional caution if celecoxib is combined with anticoagulants, antiplatelet agents, SSRIs, or SNRIs 3
• Neurologic complications (0.5% at 7 days) are more common than bleeding complications and should be the primary monitoring focus 5