Remember the article I wrote July 2 about the U.S. Food and Drug Administration advisory that anti-inflammatory pain pills like ibuprofen (Motrin, Advil) slightly increase the risk for heart attacks and strokes, sometimes leading to death? And that various studies found that diclofenac (Voltaren) increase these dangers the most compared with other pills, even at doses less than 150 milligrams a day?

Well, on Dec. 4, the FDA warned that diclofenac can also cause liver failure, liver transplantation or death, and that even Voltaren Gel applied to the skin for arthritis could do this. Liver damage can occur within the first month, but also at any time during treatment. Signs of liver damage include nausea, fatigue, itching, yellow skin or eyes, pain in the right upper stomach, or flu-like symptoms.

So blood tests are advised within 4 to 8 weeks after starting diclofenac, and the lowest dose should be used for the shortest time possible. But why not just switch to a different pain pill?

Acetaminophen (Tylenol) is the safest, as it does not increase heart disease, blood pressure, water retention or bleeding ulcers like anti-inflammatory pain pills can. Ulcers and bleeding in the stomach and intestines can happen without warning symptoms and can cause death. Anti-inflammatories can also cause kidney damage or reduced kidney function, and may impair the healing of fractures. But per the FDA, acetaminophen can cause severe liver damage if you consume three or more alcoholic drinks daily.

If you have to use an anti-inflammatory pain pill chronically, check with your physician first — she may have other ideas, or put you on daily omeprazole (Prilosec) to reduce bleeding ulcers. The safest anti-inflammatory from a heart disease and stroke viewpoint appears to be naproxen (Aleve). Slightly worse is ibuprofen, partly because it reduces the cardioprotective benefit of aspirin. Worse still are Celebrex and diclofenac, and there are theoretical reasons why etodolac (Lodine) and meloxicam (Mobic) may cause cardiovascular harm as bad as diclofenac, though they may be easier on the stomach.

I have no qualms about younger healthy folks using anti-inflammatories for sprained ankles or painful periods, but the health dangers of these pills worsen with smoking, diabetes, low HDL, high blood pressure, and other risk factors, and are especially dangerous with heart disease, low kidney function, previous bleeding ulcers, chronic use or prior strokes.