6-MP Consent Form

Intro: 6-MP (6-Mercaptopurine) is a medication that is originally used for leukemia. 6-MP is a medication that is known as an “immunomodulator because of the many ways that it affects the immune system

Uses: 6-MP has been used for many years in patients with Crohn’s and Ulcerative colitis for

• Remission of the disease (to remain symptom-free) , Decreasing and ultimately removing the use of steroids and therefore decreasing the serious potential side effects of steroids.

Remission can occur in up to 80% of people that take 6-MP.
IT MAY TAKE UP TO 3 MONTHS TO SEE BENEFITS.

Side effects: (these are the most common)

• Allergic reactions
• Decrease in white blood cells, red cells and platelets
• Nausea
• Increased risk of infections.
• Pneumonia
• Pancreatitis (rare, 6%)
• Hepatitis (rare)
• Skin cancer
• Risk of lymphoma will be one in 2,500. In general population the risk is one in 10,000

Need Follow up:

• Office visit every 3 months is required along with periodic CBC
• Hepatitis B/C test
• PPD/Chest X-ray before Rx.
• Also need pneumonia v accine-flu shot as indicated.
• Annual skin exam looking for any precancerous lesions on the skin.

Do not take Allopurinol – which is a gout medication. This will cause serious reactions

I understand that the medication has potential side effects and because of this close monitoring of blood counts is required. Blood work will be done every month for the first 3 months and every three months thereafter. I have been explained the risks, and given oopportunity to ask questions. Risks of the active disease outweight the risks of the medication. I understand and agree to start the medication.

DISCLAIMER: By typing your name below, you are signing this application electronically. You agree that your electronic signature is the legal equivalent of your manual signature on this application.