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Response to Drs. Chung et al.

in vivostudy results support this assumption. First, encapsulation of pancreatic enzymes reduces fat absorption relative to nonencapsulated counterparts (8). Second, powder formulation is better in increasing fat absorption than microtablets (9). Finally, with oral pancreatic enzyme supplementation lipolysis begins in the stomach (10). The implication of these results seems to be that formulations, which disperse easily in the stomach, are better for improving steatorrhea. Thus, if one is to take advantage of microsphere or minimicrosphere pancrelipase formulations, it is recommended that these should be ingested without capsules and with meals. We do not think that whether they are minimicrospheres or microspheres/ microtablets makes any difference as long as they are in capsules. Finally, in the study by Sternet al. (1), the patients were randomized to placebo and pancrelipase minimicrosphere groups after the open-label run-in phase. We are not comfortable with this design. The patients should have enjoyed the effects of minimicrosphere pancrelipase capsules during the open-label run-in phase, so would the patients in the placebo group not have been aware that they were taking placebos? In this study, of course, this factor should not have changed the authors’ conclusions, but we think this design is too redundant for a short and clear answer such as that minimicrosphere pancrelipase capsules are safe, tolerable, and effective. We believe a double blind crossover study would have addressed the questions they had with a smaller number of patients. In conclusion, minimicrosphere pancrelipase capsules do not seem to add anything to our current armamentarium for the treatment of pancreatic steatorrhea at this moment. However, possible deleterious effects of encapsulation of and probable advantageous effects of smaller microspheres of pancrelipases in improving steatorrhea need to be tested in humans.