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Influence of Vitamin C on Urine Dipstick Test Results

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Annals of Clinical & Laboratory Science, vol. 45, no. 4, 2015 101
Influence of Vitamin C on Urine Dipstick Test Results
Dae-Hyun Ko1, Tae-Dong Jeong1, Sollip Kim2, Hee-Jung Chung3, Woochang Lee1, Sail Chun1, and Won-Ki Min1
1Department of Laboratory Medicine, Asan Medical Center and University of Ulsan College of Medicine, Seoul,
2Department of Laboratory Medicine, Ilsan Paik Hospital, Inje University College of Medicine, Goyang, and
3Department of Laboratory Medicine, Cheil General Hospital and Women's Healthcare Centre, Kwandong University
School of Medicine, Seoul, Korea

Abstract. Background. Vitamin C is a strong reducing agent found at high levels in various foods, and it
may influence the results of urine strip tests even at an ordinary consumption levels. After oral administra-
tion, we measured urine vitamin C levels using urine strips and evaluated whether vitamin C interfered
with various test items. The utility of a urine strip with a vitamin C indicator was assessed. Methods.
Thirty-three healthy volunteers each ingested 1,000 mg of vitamin C. Their urine samples were tested for
vitamin C using a URiSCAN 11 strip (YD Diagnostics, Korea) before and after administration of vitamin
C. Standard materials were added to normal pooled urine to generate urine samples with various concen-
trations of the analytes tested (blood, bilirubin, nitrite, leukocytes, and glucose), and vitamin C was spiked
to predetermined levels. These samples were then tested using two urine strips - URiSCAN and Chemstrip
test strip (Roche Diagnostics, Germany) - to evaluate interference from vitamin C. In clinical samples with
positive vitamin C results, microscopic and chemical analyses were also conducted to examine the differ-
ences. Results. Thirteen urine samples from the 33 volunteers were positive for vitamin C before ingestion,
and all subjects were positive after ingestion. Vitamin C spiking of urine demonstrated false-negative results
at various concentrations. Of 159 specimens with positive results for vitamin C, 14 showed discrepant re-
sults after additional confirmatory tests. Conclusions. Vitamin C in urine can cause significant interference
with urine strip tests. A urine strip with a vitamin C indicator is useful to reduce the risk of incorrect results
in regard to disease states.

Key words: vitamin C, urine strip test, interference

Introduction UA strips are coated with reagents for the measure-

Vitamin C is a strong reducing agent present in
many foods. Its antioxidant properties are thought
to help prevent cardiovascular disease and aging.
For that reason, the consumption of vitamin C has
become popular. Vitamin C is also involved in can-
cer prevention and improving the quality of life of
cancer patients [1].
Urinalysis (UA) is noninvasive, simple, and one of
the most important screening tests in clinical prac-
tice. UA provides information that can lead to the
early detection of diseases in many organs. Urine
strip products are available from many diagnostic
companies worldwide, and common test items in-
clude blood, bilirubin, urobilinogen, ketones,
protein, nitrite, glucose, pH, specific gravity (SG),
and leukocytes.
Address correspondence to Won-Ki Min, M.D., Ph.D.; Department
of Laboratory Medicine, University of Ulsan College of Medicine
and Asan Medical Center, 88, Olympic-ro 43-gil, Songpa-gu, Seoul,
138-736, Korea; phone: 82 2 3010 4503; fax: 82 2 478 0884; e mail:
wkmin@ amc.seoul.kr
0091-7370/15/0400-256. © 2015 by the Association of Clinical Scientists, Inc.
ment of each analyte, and chemical reactions pro-
duce color gradations to be measured semi-quanti-
tatively. Many of these reactions are oxidation
reactions, and the degree of oxidation is propor-
tional to the concentration of the analyte tested.
The presence of vitamin C, an antioxidant, in urine
may therefore cause false-negative results for some
test items. This is especially problematic for blood
and glucose, which are detected via the peroxidase
reaction. False-negative results may also occur for
nitrite, bilirubin, and leukocytes [2,3].
Many diagnostic companies have sought to develop
UA strips resistant to such interference [4].
Alternatively, one company (YD Diagnostics,
Korea) has launched a UA strip with a vitamin C
test to additionally measure the vitamin C concen-
tration in urine. This study had two objectives: to
evaluate the utility of this vitamin C strip by testing
urine samples after vitamin C ingestion and to in-
vestigate the effects of vitamin C on other test
results.
102 Annals of Clinical & Laboratory Science, vol. 45, no. 4, 2015

Table 1. Results using the vitamin C stick, before and after consumption of a vitamin C supplement.

After/Before Negative 1+ 2+ 3+ Total

Negative 0 1 12 7 20
1+ 0 0 3 8 11
2+ 0 0 0 0 0
3+ 0 0 0 2 2

Total 0 1 15 17 33

Table 2. Interference by ascorbic acid using the URiSCAN 11 strip.

Ascorbic acid (mg/dL)

Titrated concentration 0 10 50 100 500

Glucose(mg/dL) 0 Neg. Neg. Neg. Neg. Neg.

100 ± ± ± ± Neg.
250 2+ 1+ 1+ 1+ Neg.
500 3+ 3+ 2+ 3+ Neg.
2000 4+ 4+ 4+ 4+ 3+

Blood(RBC/µL) 0 Neg. Neg. Neg. Neg. Neg.

5 ± ± ± ± Neg.
10 1+ 1+ 1+ 2+ 1+
250 3+ 3+ 3+ 3+ 3+

Leucocytes 0 Neg. Neg. Neg. Neg. Neg.

(WBC/µL) 10 ± ± Neg. Neg. Neg.
25 1+ 1+ Neg. Neg. Neg.
500 3+ 3+ Neg. Neg. Neg.

Nitrite (mg/dL) 0 Neg. Neg. Neg. Neg. Neg.

0.05 Pos. Pos. Neg. Neg. Neg.

Bilirubin (mg/dL) 0 Neg. Neg. Neg. Neg. Neg.

0.5 1+ 1+ Neg. Neg. Neg.
1 2+ 2+ 2+ 1+ Neg.
3 3+ 3+ 3+ 2+ 1+

Materials and Methods
This study was conducted in accordance with the
Declaration of Helsinki. It was approved by the Asan
Medical Center Institutional Review Board (Project
#2008-0291).
Test for vitamin C in urine before and after oral ad-
ministration. We recruited 33 healthy volunteers for the
experiment. Their urine samples were tested for vitamin
C using a urine strip (URiSCAN 11 strip, YD
Diagnostics, Korea) before and 4-8 hours after oral ad-
ministration of vitamin C (1,000 mg). The results were
scored as ‘0’ for 0-9 mg/dL, ‘1+’ for 10-16 mg/dL, ‘2+’
for 17-35 mg/dL, and ‘3+’ for 35 mg/dL or more of vi-
tamin C.
Interference test for pooled samples. Pooled urine sam-
ples were prepared from healthy volunteers whose urine
samples were normal on all urine strip tests. Standard
materials were then added to the pooled urine to create
predetermined concentrations of the analytes tested
(blood: 0, 5, 10, and 250 RBC/µL, bilirubin: 0, 0.5, 1.0,
and 3.0 mg/dL, nitrite: 0 and 0.05 mg/dL, WBCs: 0, 10,
25, and 500 WBC/µL, glucose: 0, 100, 250, 500, and
2,000 mg/dL).
The samples were spiked with varying amounts of vita-
min C, adjusted to final concentrations of 10, 50, 100,
and 500 mg/dL. A random urine sample could have vi-
tamin C up to 19350 μmol/L (about 340 mg/dL) [2].
Some of the urine collected after vitamin C administra-
tion consistently showed 3+ after several-fold dilution.

Influence of vitamin C on urine dip stick test results
Therefore, the range was extended to 500 mg/dL, al-
though the cut-off for ‘3+’ was 35 mg/dL, to provide evi-
dence for the relation between vitamin C and UA strip
results. The samples were then tested for blood, biliru-
bin, nitrite, glucose, and leukocytes. These tests were
conducted using the URiSCAN 11 strip, which is the
most widely used UA strip in Korea [5], and the
Chemstrip Test Strip (Roche Diagnostics, Germany),
which is relatively resistant to interference by vitamin C
[4].
Interference tests using clinical samples. To detect vita-
min C using a URiSCAN 11 strip, we tested urine sam-
ples requested for UA from July 2008 to August 2008 at
Asan Medical Center, Korea. In total, 676 samples were
tested, and 159 samples (24%) were positive for vitamin
C, with a reaction intensity of ‘1’ or greater. All of these
samples were retested using reference methods – micro-
scopic analysis of urine sediment to quantify RBC and
WBC, and chemical analysis of glucose using an auto-
matic chemistry analyzer – to compare the results with
those from the UA strip.
Results
Test for vitamin C in urine before and after oral
administration. Of the 33 volunteers, 39.4%
(13/33) were positive and the others (60.6%,
20/33) were negative for vitamin C before inges-
tion of vitamin C. All subjects were positive after
vitamin C ingestion. One specimen (3.0%) showed
a 1+ reaction intensity, 15 (42.4%) showed 2+, and
the remaining 17 (51.5%) showed 3+ (Table 1).
Interference test with pooled samples. The test re-
sults using the URiSCAN are shown in Table 2.
The samples with 100, 250, or 500 mg/dL glucose
showed false-negatives with 500 mg/dL vitamin C,
and the blood cell tests were also negative at the
same concentration of vitamin C for the urine sam-
ples with 5 RBC/µL. Vitamin C at 50 mg/dL or
greater concentrations caused the test results to
change to negative for nitrite and WBC amounts
over the ranges tested. Samples with 0.5 mg/dL
bilirubin showed negative results with 50 mg/dL or
greater vitamin C, and the urine samples with high-
er bilirubin levels (1 and 3 mg/dL) were generally
not affected by vitamin C.
Table 3 shows the results of using the Chemstrip.
Interestingly, 500 mg/dL vitamin C increased the
reaction strength for glucose and blood cells. The
nitrite and leukocyte results were similar to those of
URiSCAN, except for the nitrite reaction at 10 mg/
dL of vitamin C.
103
Interference test using clinical samples. In total,
159 specimens (24 %) were positive for vitamin C
at reaction intensities of ‘1+’ or more. The positive
samples were tested for discrepancy between the
URiSCAN strip and reference methods. Of the
specimens, 14 (8.8%) had discrepancies between
the strip results and additional confirmatory tests,
as shown in Table 4. Of the specimens, five were
falsely negative for blood cells and eight were false-
ly negative for leukocytes when using the strip.
One specimen was negative for glucose according
to the URiSCAN strip, contrary to the results ob-
tained using the automatic chemistry analyzer
(122.5 mg/dL).
Discussion
After ingestion of a typical dose of vitamin C in
dietary supplement form, all participant urine sam-
ples were positive for vitamin C. High concentra-
tions of vitamin C in urine can cause false decreases
in dipstick reactions, with a variable degree of in-
terference, depending on the analytes and their
concentrations. We confirmed the results again in
clinical samples that were positive for vitamin C.
In the 1980s, the antioxidant properties of vitamin
C were shown to be related to its anticancer effects
[6]. In some studies, intravenous administration of
high-dose vitamin C to terminal cancer patients
was relatively tolerable and safe [7,8]. In three ter-
minal cancer patients, high-dose vitamin C, ad-
ministered intravenously, showed long-term tu-
mor-regressing effects [9]. Moreover, in a study
evaluating the risk for colorectal cancer in 715
colorectal cancer patients and 727 age- and gender-
matched community controls, vitamin C ingestion
was effective in reducing the risk of colorectal can-
cer in a dose-dependent manner [10]. Vitamin C
administration may also improve the quality of life
of terminal cancer patients [11].
It is well known that vitamin C in urine can cause
false-negative results for blood cells and glucose,
the tests for which specifically use oxidation reac-
tions. In this study, vitamin C interfered with these
reactions as expected when using the URiSCAN
test, but interference was also seen with higher con-
centrations of vitamin C using the Chemstrip test.
Residues of strongly oxidizing cleaning agents in
the urine container may also cause false-positive re-
sults when using the Chemstrip (according to the
104 Annals of Clinical & Laboratory Science, vol. 45, no. 4, 2015

Table 3. Interference by ascorbic acid using the Chemstrip.

Ascorbic acid (mg/dL)

Titrated concentration 0 10 50 100 500

Glucose(mg/dL)
0 Neg. Neg. Neg. Neg. 3+
100 ± 1+ 1+ 1+ 3+
250 2+ 2+ 2+ 2+ 3+
500 3+ 3+ 3+ 3+ 3+
2000 3+ 3+ 3+ 3+ 3+

Blood(RBC/µL)
0 Neg. Neg. Neg. Neg. 4+
5 ± 1+ ± ± 4+
10 1+ 1+ 1+ 2+ 4+
250 4+ 4+ 4+ 4+ 4+

Leucocytes 0 Neg. Neg. Neg. Neg. Neg.

(WBC/µL) 10 ± ± Neg. Neg. Neg.
25 1+ 1+ Neg. Neg. Neg.
500 2+ 2+ Neg. Neg. Neg.

Nitrite(mg/dL) 0 Neg. Neg. Neg. Neg. Neg.

0.05 Pos. Neg. Neg. Neg. Neg.

Bilirubin(mg/dL) 0 Neg. Neg. Neg. Neg. Neg.

0.5 Neg. Neg. Neg. Neg. Neg.
1 ± ± ± Neg. Neg.
3 2+ 2+ 1+ ± Neg.

Table 4. Discrepant results due to the presence of vitamin C between the urine strip test and confirmatory reference
methods.

Specimen Test Urine strip Reference method Vitamin C

number results results concentration

1 Blood Negative 3-5 RBC/HPF 2+

2 Negative 3-5 RBC/HPF 2+
3 Negative 6-10 RBC/HPF 3+
4 Negative 3-5 RBC/HPF 3+
5 Negative 3-4 RBC/HPF 3+
6 Leukocytes Negative 3-5 WBC/HPF 1+
7 Negative 3-5 WBC/HPF 1+
8 Negative 3-5 WBC/HPF 2+
9 Negative 3-5 WBC/HPF 2+
10 Negative 3-5 WBC/HPF 2+
11 Negative 6-10 WBC/HPF 2+
12 Negative 3-5 WBC/HPF 3+
13 Negative 6-10 WBC/HPF 3+
14 Glucose Negative 122.5 mg/dL 3+

HPF: high power field.

 Influence of vitamin C on urine dip stick test results 105
Roche Diagnostics product insert), but additional
experiments are needed to clarify the exact cause(s).
The Chemstrip uses iodate or potassium iodide
chromogen as a scavenger to reduce interference
from vitamin C [12,13]. The provider claims that it
is not influenced by vitamin C when the glucose
concentration exceeds 100 mg/dL, but it cannot
eliminate interference and provides no information
about interference at lower concentrations of glu-
cose [3]. Berg demonstrated that with 30 mg/dL
vitamin C, 23 of 30 specimens with glucose levels
of 50 mg/dL showed false-negative results [14].
Brigden et al. also reported that specimens with
glucose levels of 5.6 mmol/L (100.9 mg/dL) or
greater were resistant to interference by vitamin C
at a high concentration (10,000 µmol/L), but spec-
imens with glucose levels of 1.4 mmol/L (25.2 mg/
dL) gave false-negative results when the vitamin C
concentration was 500 µmol/L (8.8 mg/dL) [2].
Nitrite tests gave false-negative results at lower con-
centrations of vitamin C with both strips. The
Chemstrip was more resistant to vitamin C for
blood and glucose than was the URiSCAN 11 strip,
and vice versa for nitrite. The Multistix strip (Bayer
Healthcare, USA), which is the second-most widely
used product in Korea [5], is also influenced by vi-
tamin C at 25 mg/dL or greater concentrations,
causing false-negative nitrite results. Bilirubin tests
using both strips also showed weaker results with
higher concentrations of vitamin C. Thus, it is rea-
sonable to add a test item for vitamin C to detect
possible interference.
Overall, the proportion of samples with false nega-
tive results due to vitamin C was small. However,
when viewing an individual test with all ‘normal’
results and positive vitamin C, false negatives due
to vitamin C cannot be ruled out. Thus the vitamin
C strip may help physicians to more appropriately
interpret UA results.
To reduce costs, ‘normal’ UA test results are not
usually followed up with additional confirmatory
tests. However, the results of this study show that
overlooking the presence of vitamin C in urine may
lead to potentially serious false-negative results, es-
pecially for glucose and blood. Thus, a vitamin
C-resistant strip or a strip with a vitamin
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C indicator is a preferred solution. For specimens
positive for vitamin C, the results should be report-
ed with a comment, such as “Vitamin C in urine
can cause false-negative results for glucose and
blood cells. Repeating a test after restriction of vita-
min C consumption is recommended,” or the spec-
imens should be subjected to additional follow-up
analyses. Vitamin C-resistant strips do not elimi-
nate possible interference by high concentrations of
vitamin C; thus, using a strip with a vitamin C in-
dicator is preferable.
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