test tube of different color urine

What clinical presentation and medication is associated with this urinary discoloration?

  1. Critical illness requiring intubation and propofol sedation
  2. Cyanide toxicity requiring sodium thiosulfate
  3. Iron toxicity treated with deferoxamine
  4. Refractory vasoplegic shock treated with methylene blue
  5. Septic shock treated with vancomycin and cefepime

3. Iron toxicity treated with deferoxamine


  • Deferoxamine is the treatment for severe iron toxicity [1]. Deferoxamine binds with ferric iron (Fe3+) to form ferrioxamine, a water-soluble compound excreted in the urine. As ferrioxamine is excreted, the patient’s urine becomes an orange or brown rusty hue, classically referred to as vin rosé urine [1,2].

For iron toxicity, what are the indications for deferoxamine? [1,2]

  • Severe symptoms such as hypovolemia, shock, metabolic acidosis
  • Persistent and severe GI symptoms
  • Lethargy or toxic appearance
  • Serum iron level greater than 500 mcg/dL

What is the dosage of deferoxamine for iron toxicity? [1]

  • Initial dosing starts at 5 mg/kg/hr intravenously.
  • Increase to 15 mg/kg/hr with a max dose of 6-8 g in 24 hours.

What are the potential adverse effects of acute deferoxamine infusion? [1, 3, 4]

  • Hypotension is generally the rate-limiting factor for the infusion rate.
  • Acute Respiratory Distress Syndrome (ARDS) may occur, particularly if use exceeds 24 hours.
  • Increased risk of infection with atypical organisms such as mucormycosis, Yersinia, and Vibrio

What is the significance of vin rosé urine? [1, 3, 5]

  • Vin rosé urine is simply indicates the excretion of ferrioxamine and is not harmful.
  • This color could be mistaken for blood, renal injury, or other toxicity.
  • Resolution of vin rosé urine is not an indication for cessation of treatment.

What other medications can cause orange/red/brown urine? [6-9]

  • Entacapone
  • Hydroxocobalamin
  • Levodopa
  • Phenazopyridine
  • Rifampin
  • Senna
  • Sulfasalazine

Clinical Pearls

  • Deferoxamine binds with free iron and is excreted as ferrioxamine in urine, causing a rusty discoloration known as vin rosé urine.
  • Vin rosé urine is a sign of successful chelation and should not be mistaken for blood or renal injury.


  1. Perrone J. Iron. In: Nelson LS, Goldfrank LR et al (eds): Goldfrank’s Toxicologic Emergencies. McGraw-Hill Education; 2019
  2. Madiwale T, Liebelt E. Iron: not a benign therapeutic drug. Curr Opin Pediatr 2006;18(2):174-9.  PMID 16601499
  3. Velasquez J, Wray AA. Deferoxamine. 2023 May 22. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2023 Jan–. PMID: 32491586
  4. Yuen HW, Becker W. Iron Toxicity. 2023 Jun 26. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2023 Jan–. PMID: 29083637
  5. Fernández S, Castro P, Nogué S, Nicolás JM: Acute iron intoxication: change in urine color during chelation therapy with deferoxamine. Intensive Care Med 2014; 40(1):104. PMID 24072332
  6. Baranwal AK, Singhi SC: Acute iron poisoning: management guidelines. Indian Pediatr 2003;40(6):534-40.  PMID 12824662
  7. Martínez, E., Collazos, J., & Mayo, J. Hypersensitivity reactions to rifampin: Pathogenetic mechanisms, clinical manifestations, management strategies, and review of the anaphylactic-like reactions. Medicine (Baltimore) 1999;78(6):361-9. PMID 10575418
  8. Kaakkola S. Clinical pharmacology, therapeutic use and potential of COMT inhibitors in Parkinson’s disease. Drugs. 2000 Jun;59(6):1233-50. PMID: 10882160
  9. The meaning behind the color of urine. The Meaning Behind the Color of Urine – Urology Care Foundation. American Urological Society. 22 Aug 2018.
Allison Frazure, MD

Allison Frazure, MD

Emergency Medicine Resident
Carolinas Medical Center
Allison Frazure, MD

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Kathryn T. Kopec, DO

Kathryn T. Kopec, DO

Associate Professor of Emergency Medicine
Medical Toxicologist
Carolinas Medical Center