Introduction <p>This study investigated the association between medication status and total hip arthroplasty (THA) complications in patients with inflammatory bowel disease (IBD), considering varying illness severities.</p> Materials and methods <p>This retrospective analysis of the National Health Insurance Review and Assessment Service database in South Korea, included patients undergoing unilateral THA between 2012 and 2022, specifically those diagnosed with IBD. Propensity score matching was used to adjust for baseline characteristics between IBD and non-IBD cohorts, with a matching ratio of 1:10.</p> Results <p>There was a significant difference between the IBD (<i>n</i> = 962) and non-IBD matched groups (<i>n</i> = 9,620) in terms of chronic periprosthetic joint infection (PJI) (2.1 vs. 1.3%, <i>P</i>= 0.03) but not with acute PJI or other surgical complications (periprosthetic fracture, dislocation, and aseptic loosening). While medication use overall was not associated with PJI, only corticosteroid use among IBD medications was significantly associated with PJI among IBD medications (OR: 2.79 [1.03–10.68], <i>P</i> = 0.04). Specifically, multivariable analysis revealed that corticosteroid use within one year before THA was associated with a significant increase in PJI risk (OR: 3.30 [1.21–10.86], <i>P</i> = 0.02). Patients with IBD who were not using steroids did not show an increased risk of PJI.</p> Conclusions <p>While IBD increased the risk of chronic PJI, the risk was remarkable in patients using steroids, particularly in the context of poorly controlled IBD and acute flares-up. Preoperative steroid use within one year before THA conferred the greatest risk. Attention should be directed towards recognizing the risk of steroid use before THA.</p> Level of evidence <p>Level III, Prognostic.</p>