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Microsoft word - form 416 rev 05-1


Please tell us if you are now taking or if you have EVER taken any of these medications:

Proscar (finasteride)  usually given for prostate gland enlargement
Avodart or Jalyn (dutasteride)  usually given for prostate enlargement
Propecia (finasteride)  usually given for baldness
Accutane (Amnesteem, Claravis, Sotret, isotretinoin)  usually given for severe acne
Soriatane (acitretin) – usually given for severe psoriasis
Tegison (etretinate) – usually given for severe psoriasis
Growth Hormone from Human Pituitary Glands  used usually for children with delayed or
Insulin from Cows (Bovine, or Beef, Insulin)  used to treat diabetes
Hepatitis B Immune Globulin – given following an exposure to hepatitis B.
NOTE: This is different from the hepatitis B vaccine which is a series of 3 injections given over
a 6 month period to prevent future infection from exposures to hepatitis B.
Unlicensed Vaccine – usually associated with a research protocol

Remicade, Enbrel, Humira, Orencia, Simponi Azasan, Imuran, Methotrexate, Chemotherapy
Drugs, Radiation – given as treatment for cancer or some connective tissue diseases

Immunosuppressant Drugs (cyclosporins, azathioprines, monoclonal antibodies) – anti-rejection
drugs used to prevent the body from rejecting a transplanted organ


 If you have taken or are taking Proscar, Avodart, Jalyn, Propecia, Accutane, Soriatane, or Tegison, these
medications can cause birth defects. Your donated blood could contain high enough levels to damage the unborn baby if transfused to a pregnant woman. Once the medication has been cleared from your blood, you may donate again. Following the last dose, the deferral period is one month Proscar, Propecia and Accutane, six months for Avodart and Jalyn, and three years for Soriatane. Tegison is a permanent deferral.  Growth hormone from human pituitary glands was prescribed for children with delayed or impaired growth. The
hormone was obtained from human pituitary glands, which are found in the brain. Some people who took this hormone developed a rare nervous system condition called Creutzfeldt-Jakob Disease (CJD, for short). The deferral is permanent.  Insulin from cows (bovine, or beef, insulin) is an injected material used to treat diabetes. If this insulin was imported
into the US from countries in which “Mad Cow Disease” has been found, it could contain material from infected cattle. There is concern that "Mad Cow Disease" is transmitted by transfusion. The deferral is indefinite.  Hepatitis B Immune Globulin (HBIG) is an injected material used to prevent infection following an exposure to
hepatitis B. HBIG does not prevent hepatitis B infection in every case, therefore persons who have received HBIG must wait 12 months to donate blood to be sure they were not infected since hepatitis B can be transmitted through transfusion to a patient.  Unlicensed Vaccine is usually associated with a research protocol and the effect on blood transmission is unknown.
Deferral is one year unless otherwise indicated by Medical Director.  Remicade, Enbrel, Humira, Orencia, Simponi, Azasan, Imuran, Methotrexate, Chemotherapy Drugs, and
Radiation are treatments for arthritis, cancer or auto-immune diseases. If you are undergoing treatment with these drugs,
you should wait at least one year after your body has recovered until you donate blood.
Immunosuppressant Drugs suppress your immune system, and you should not donate blood when your immunity to

Source: http://www.scbb.org/donateblood/Form%20416%20rev%2005-11.pdf

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Probucol with colestipol in the treatment of hypercholesterolemia

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