Practical guidelines for managing GERD,” (December 2009) was weak in some areas. First, the section on lifestyle modification dismissed an important aspect of the problem that patients can control. Not every patient smokes, has high caffeine or chocolate intake at supper, eats heavy meals before lying down, or drinks water throughout the night. But a reasonable discussion of these behaviors is worthwhile. I have found that prescribing a proton pump inhibitor (PPI) without this discussion usually leads to poor outcomes and taking an expensive medication endlessly without results.

Tolerability is often confused with long-term safety. With studies emerging about increased fracture risk in women who are on PPIs for years, clinicians need to ask if we can periodically try to get patients off these medications or re- assess the associated risk factors.—Terry Ashby, NP-C, Wilmington, N.C. (137-19)