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Vitamin D target value and refund

Question
Hello,

I was just searching about your expert advice platform and found the statement that the target value for vitamin D is 20ng/ml. This is not according to the newest recommendations which suggest at least 30ng/ml.

Question: Most patients do not get their vitamin D preparations reimbursed (what is probably not such a big problem due to the low price). Could, however, highly dosed vitamin D be prescribed for (almost all) CF patients and thus become refundable (e.g. Dekristol 20.000 IU; taken according to requirements for example once per week or once per month…)? Vitamin D can be stored in the body, doesn't it…???

Answer
Hello,

Please let me answer your comment and your question as follows:

1) In literature it is discussed controversially which serum level should be indicated as target value for vitamin D. Many laboratories consider the range from 15-30 ng/ml being the normal range and thus the value of 20 ng/ml is well accepted by many clinicians as a good target value. Especially in the USA, however, there are working groups indicating a target value of > 30 ng/ml.

2) There are studies with adult CF patients having a low vitamin D serum level initially where extremely high doses of vitamin D (400.000 IU chole/ergocalciferol daily for 2 weeks or 50.000 IU chole/ergocalciferol daily for 4 weeks, oral administration) led to a return to normal in 68% of the patients. According to these studies no side effects in terms of hypercalcemia were observed.

The situation in Germany with regard to prescription can be described as follows:

A prescription of vitamin D is usually only accepted for children up to 12 years and the prescreption has to contain the remark "vitamin D absorption dysfunction". Futhermore, the health insurances accept a prescription if a long-term cortisone therapy is performed. In this case a calcium preparation has to be prescribed at the same time.

Currently, the health insurances do not accept a prescription for vitamin D if a laboratory testing has only proven a vitamin D deficiency.
Incomprehensibly, the health insurances only cover the costs for a vitamin D therapy if there is evidence for an osteoporosis with damages of the bone structure in form of upper/superior end plate deformities of vertebral bodies, bone fracture or severe back pain due to backbone damage. Whether the therapy costs are covered by the health insurance in this case is thus not depending on the costs of a preparation but on the health condition of the patient.

However, it has always been helpful in the single case to pass in to the health insurance a medical opinion where the special case is described in detail.

Best regards,
Dr. H.-G. Posselt
15.05.2012
15.5.12
Helpful are in this case the European bone mineralisation guidelines:
Serment-Gaudelus et al. in the Journal of Cystic Fibrosis 2011, 10 Suppl 2:S16-S23: “European cystic fibrosis bone mineralization guidelines.”:
..."Serum 25-hydroxyvitamin D is the best biochemical marker of vitamin D status, yet optimal lower and upper thresholds for desirable levels in the CF population are still a matter of debate. A threshold level of 20ng/ml to prevent viatmin D deficiency has been suggested in the current guidelines. A threshold of 20ng/ml has also been reommended by the Lawson Wilkins Pediatric endocrine Society based upon pediatric data available to date. This contrasts with the North American CF bone health consensus statement which recommends achieving a mimimum 25-hydroxy vitamin D concentration of 30ng/ml.(...).Therefore current data show no evidence to demonstrate a beneficial effect of levels above 30ng/ml on bone mineral density, fractures and markers of bone metabolism in people with CF."
D. d'Alquen