ACMT Toxicology Visual Pearl: Who Doesn’t Like a Nice Rosé?

3. Iron toxicity treated with deferoxamine

Background

• 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.