Indications/Uses
Adults, elderly and children >1 year for the relief of the inflammatory and pruritic manifestations of steroid-responsive dermatoses. These include the following: Psoriasis (excluding widespread plaque psoriasis), recalcitrant dermatoses, lichen planus, discoid lupus erythematosus, other skin conditions which do not respond satisfactorily to less potent steroids.
Dosage/Direction for Use
Cream: Creams are especially appropriate for moist or weeping surfaces.
Ointment: Ointments are especially appropriate for dry, lichenified or scaly lesions.
Adults, Elderly and Children >1 year: Apply thinly and gently rub in using only an enough amount to cover the entire affected area once or twice daily for up to 4 weeks until improvement occurs, then reduce the frequency of application or change the treatment to a less potent preparation. Allow adequate time for absorption after each application before applying an emollient.
Repeated short courses of Dermovate may be used to control exacerbations.
In more resistant lesions, especially where there is hyperkeratosis, the effect of Dermovate can be enhanced, if necessary, by occluding the treatment area with polyethene film.
Overnight occlusion only is usually adequate to bring about a satisfactory response. Thereafter, improvement can usually be maintained by application without occlusion.
If the condition worsens or does not improve within 2-4 weeks, treatment and diagnosis should be re-evaluated.
Treatment should not be continued for >4 weeks. If continuous treatment is necessary, a less potent preparation should be used.
The maximum weekly dose should not exceed 50 g/week.
Atopic Dermatitis (Eczema): Therapy with Dermovate should be gradually discontinued once control is achieved and an emollient continued as maintenance therapy.
Rebound of preexisting dermatoses can occur with abrupt discontinuation of Dermovate.
Recalcitrant Dermatoses: Patients Who Frequently Relapse: Once an acute episode has been treated effectively with a continuous course of topical corticosteroid, intermittent dosing (once daily, twice weekly, without occlusion) may be considered. This has been shown to be helpful in reducing the frequency of relapse.
Application should be continued to all previously affected sites or to known sites of potential relapse. This regimen should be combined with routine daily use of emollients. The condition and the benefits and risks of continued treatment must be re-evaluated on a regular basis.
Children: Clobetasol propionate is contraindicated in children under one year of age. Children are more likely to develop local and systemic side effects of topical corticosteroids and in general, require shorter courses and less potent agents than adults.
Care should be taken when using Dermovate to ensure the amount applied is the minimum that provides therapeutic benefit.
Elderly: Clinical studies have not identified differences in responses between the elderly and younger patients. The greater frequency of decreased hepatic or renal function in the elderly may delay elimination if systemic absorption occurs. Therefore, the minimum quantity should be used for the shortest duration to achieve the desired clinical benefit.
Renal/Hepatic Impairment: In case of systemic absorption (when application is over a large surface area for a prolonged period), metabolism and elimination may be delayed, therefore increasing the risk of systemic toxicity. Therefore, the minimum quantity should be used for the shortest duration to achieve the desired clinical benefit.
Ointment: Ointments are especially appropriate for dry, lichenified or scaly lesions.
Adults, Elderly and Children >1 year: Apply thinly and gently rub in using only an enough amount to cover the entire affected area once or twice daily for up to 4 weeks until improvement occurs, then reduce the frequency of application or change the treatment to a less potent preparation. Allow adequate time for absorption after each application before applying an emollient.
Repeated short courses of Dermovate may be used to control exacerbations.
In more resistant lesions, especially where there is hyperkeratosis, the effect of Dermovate can be enhanced, if necessary, by occluding the treatment area with polyethene film.
Overnight occlusion only is usually adequate to bring about a satisfactory response. Thereafter, improvement can usually be maintained by application without occlusion.
If the condition worsens or does not improve within 2-4 weeks, treatment and diagnosis should be re-evaluated.
Treatment should not be continued for >4 weeks. If continuous treatment is necessary, a less potent preparation should be used.
The maximum weekly dose should not exceed 50 g/week.
Atopic Dermatitis (Eczema): Therapy with Dermovate should be gradually discontinued once control is achieved and an emollient continued as maintenance therapy.
Rebound of preexisting dermatoses can occur with abrupt discontinuation of Dermovate.
Recalcitrant Dermatoses: Patients Who Frequently Relapse: Once an acute episode has been treated effectively with a continuous course of topical corticosteroid, intermittent dosing (once daily, twice weekly, without occlusion) may be considered. This has been shown to be helpful in reducing the frequency of relapse.
Application should be continued to all previously affected sites or to known sites of potential relapse. This regimen should be combined with routine daily use of emollients. The condition and the benefits and risks of continued treatment must be re-evaluated on a regular basis.
Children: Clobetasol propionate is contraindicated in children under one year of age. Children are more likely to develop local and systemic side effects of topical corticosteroids and in general, require shorter courses and less potent agents than adults.
Care should be taken when using Dermovate to ensure the amount applied is the minimum that provides therapeutic benefit.
Elderly: Clinical studies have not identified differences in responses between the elderly and younger patients. The greater frequency of decreased hepatic or renal function in the elderly may delay elimination if systemic absorption occurs. Therefore, the minimum quantity should be used for the shortest duration to achieve the desired clinical benefit.
Renal/Hepatic Impairment: In case of systemic absorption (when application is over a large surface area for a prolonged period), metabolism and elimination may be delayed, therefore increasing the risk of systemic toxicity. Therefore, the minimum quantity should be used for the shortest duration to achieve the desired clinical benefit.
Overdosage
Symptoms: Topically applied Dermovate may be absorbed in sufficient amounts to produce systemic effects. Acute overdosage is very unlikely to occur, however, in the case of chronic overdosage or misuse, the features of hypercortisolism may occur (see Adverse Reactions).
Treatment: In the event of overdose, Dermovate should be withdrawn gradually by reducing the frequency of application or by substituting a less potent corticosteroid because of the risk of glucocorticosteroid insufficiency.
Further management should be as clinically indicated or as recommended by the national poisons center, where available.
Treatment: In the event of overdose, Dermovate should be withdrawn gradually by reducing the frequency of application or by substituting a less potent corticosteroid because of the risk of glucocorticosteroid insufficiency.
Further management should be as clinically indicated or as recommended by the national poisons center, where available.
Contraindications
Untreated cutaneous infections, rosacea, acne vulgaris, pruritus without inflammation, perianal and genital pruritus, perioral dermatitis. Dermatoses in children <1 year, including dermatitis.
Special Precautions
Dermovate should be used with caution in patients with a history of local hypersensitivity to corticosteroids or to any of the excipients of Dermovate. Local hypersensitivity reactions (see Adverse Reactions) may resemble symptoms of the condition under treatment.
Manifestations of hypercortisolism (Cushing's syndrome) and reversible hypothalamic-pituitary-adrenal (HPA) axis suppression, leading to glucocorticosteroid insufficiency, can occur in some individuals as a result of increased systemic absorption of topical steroids. If either of the previously mentioned conditions are observed, withdraw the drug gradually by reducing the frequency of application or by substituting a less potent corticosteroid. Abrupt withdrawal of treatment may result in glucocorticosteroid insufficiency (see Adverse Reactions).
Risk Factors for Increased Systemic Effects: Potency and formulation of topical steroid; duration of exposure; application to a large surface area; use on occluded areas of the skin [eg, on intertriginous areas or under occlusive dressings (in infants, the nappy may act as an occlusive dressing)]; increasing hydration of the stratum corneum; use on thin skin areas eg, the face; use on broken skin or other conditions where the skin barrier may be impaired.
In comparison with adults, children and infants may absorb proportionally larger amounts of topical corticosteroids and thus, be more susceptible to systemic adverse effects. This is because children have an immature skin barrier and a greater surface area-to-body weight ratio compared with adults.
Infection Risk with Occlusion: Bacterial infection is encouraged by the warm, moist conditions within skin folds or caused by occlusive dressings. When using occlusive dressings, the skin should be cleansed before a fresh dressing is applied.
Use in Psoriasis: Topical corticosteroids should be used with caution in psoriasis as rebound relapses, development of tolerances, risk of generalized pustular psoriasis and development of local or systemic toxicity due to impaired barrier function of the skin have been reported in some cases. If used in psoriasis, careful patient supervision is important.
Concomitant Infection: Appropriate antimicrobial therapy should be used whenever treating inflammatory lesions which have become infected. Any spread of infection requires withdrawal of topical corticosteroid therapy and administration of appropriate antimicrobial therapy.
Chronic Leg Ulcers: Topical corticosteroids are sometimes used to treat the dermatitis around chronic leg ulcers. However, this use may be associated with a higher occurrence of local hypersensitivity reactions and an increased risk of local infection.
Application to the Face: Application to the face is undesirable as this area is more susceptible to atrophic changes. If used on the face, treatment should be limited to only a few days.
Application to the Eyelids: If applied to the eyelids, care is needed to ensure that Dermovate does not enter the eye as cataract and glaucoma might result from repeated exposure.
Effects on the Ability to Drive or Operate Machinery: There have been no studies to investigate the effect of Dermovate on driving performance or on the ability to operate machinery. A detrimental effect on such activities would not be anticipated from the adverse reaction profile of Dermovate.
Fertility: There are no data in humans to evaluate the effect of topical corticosteroids on fertility. Clobetasol administered SC to rats had no effect upon mating performance; however, fertility was decreased at the highest dose (see Toxicology: Pre-clinical safety data under Actions).
Use in Pregnancy: There are limited data on the use of Dermovate in pregnant women. Topical administration of corticosteroids to pregnant animals can cause abnormalities of fetal development (see Toxicology: Pre-clinical safety data under Actions). The relevance of this finding to humans has not been established. Administration of Dermovate during pregnancy should only be considered if the expected benefit to the mother outweighs the risk to the fetus. The minimum quantity should be used for the minimum duration.
Use in Lactation: The safe use of topical corticosteroids during lactation has not been established. It is not known whether the topical administration of corticosteroids could result in sufficient systemic absorption to produce detectable amounts in breast milk. Administration of Dermovate during lactation should only be considered if the expected benefit to the mother outweighs the risk to the infant. If used during lactation, Dermovate should not be applied to the breasts to avoid accidental ingestion by the infant.
Use in Children: In infants and children <12 years, long-term continuous topical corticosteroid therapy should be avoided where possible as adrenal suppression can occur.
Children are more susceptible to develop atrophic changes with the use of topical corticosteroids. If Dermovate is required for use in children, it is recommended that the treatment be limited to only a few days and reviewed weekly.
Manifestations of hypercortisolism (Cushing's syndrome) and reversible hypothalamic-pituitary-adrenal (HPA) axis suppression, leading to glucocorticosteroid insufficiency, can occur in some individuals as a result of increased systemic absorption of topical steroids. If either of the previously mentioned conditions are observed, withdraw the drug gradually by reducing the frequency of application or by substituting a less potent corticosteroid. Abrupt withdrawal of treatment may result in glucocorticosteroid insufficiency (see Adverse Reactions).
Risk Factors for Increased Systemic Effects: Potency and formulation of topical steroid; duration of exposure; application to a large surface area; use on occluded areas of the skin [eg, on intertriginous areas or under occlusive dressings (in infants, the nappy may act as an occlusive dressing)]; increasing hydration of the stratum corneum; use on thin skin areas eg, the face; use on broken skin or other conditions where the skin barrier may be impaired.
In comparison with adults, children and infants may absorb proportionally larger amounts of topical corticosteroids and thus, be more susceptible to systemic adverse effects. This is because children have an immature skin barrier and a greater surface area-to-body weight ratio compared with adults.
Infection Risk with Occlusion: Bacterial infection is encouraged by the warm, moist conditions within skin folds or caused by occlusive dressings. When using occlusive dressings, the skin should be cleansed before a fresh dressing is applied.
Use in Psoriasis: Topical corticosteroids should be used with caution in psoriasis as rebound relapses, development of tolerances, risk of generalized pustular psoriasis and development of local or systemic toxicity due to impaired barrier function of the skin have been reported in some cases. If used in psoriasis, careful patient supervision is important.
Concomitant Infection: Appropriate antimicrobial therapy should be used whenever treating inflammatory lesions which have become infected. Any spread of infection requires withdrawal of topical corticosteroid therapy and administration of appropriate antimicrobial therapy.
Chronic Leg Ulcers: Topical corticosteroids are sometimes used to treat the dermatitis around chronic leg ulcers. However, this use may be associated with a higher occurrence of local hypersensitivity reactions and an increased risk of local infection.
Application to the Face: Application to the face is undesirable as this area is more susceptible to atrophic changes. If used on the face, treatment should be limited to only a few days.
Application to the Eyelids: If applied to the eyelids, care is needed to ensure that Dermovate does not enter the eye as cataract and glaucoma might result from repeated exposure.
Effects on the Ability to Drive or Operate Machinery: There have been no studies to investigate the effect of Dermovate on driving performance or on the ability to operate machinery. A detrimental effect on such activities would not be anticipated from the adverse reaction profile of Dermovate.
Fertility: There are no data in humans to evaluate the effect of topical corticosteroids on fertility. Clobetasol administered SC to rats had no effect upon mating performance; however, fertility was decreased at the highest dose (see Toxicology: Pre-clinical safety data under Actions).
Use in Pregnancy: There are limited data on the use of Dermovate in pregnant women. Topical administration of corticosteroids to pregnant animals can cause abnormalities of fetal development (see Toxicology: Pre-clinical safety data under Actions). The relevance of this finding to humans has not been established. Administration of Dermovate during pregnancy should only be considered if the expected benefit to the mother outweighs the risk to the fetus. The minimum quantity should be used for the minimum duration.
Use in Lactation: The safe use of topical corticosteroids during lactation has not been established. It is not known whether the topical administration of corticosteroids could result in sufficient systemic absorption to produce detectable amounts in breast milk. Administration of Dermovate during lactation should only be considered if the expected benefit to the mother outweighs the risk to the infant. If used during lactation, Dermovate should not be applied to the breasts to avoid accidental ingestion by the infant.
Use in Children: In infants and children <12 years, long-term continuous topical corticosteroid therapy should be avoided where possible as adrenal suppression can occur.
Children are more susceptible to develop atrophic changes with the use of topical corticosteroids. If Dermovate is required for use in children, it is recommended that the treatment be limited to only a few days and reviewed weekly.
Use In Pregnancy & Lactation
Fertility: There are no data in humans to evaluate the effect of topical corticosteroids on fertility. Clobetasol administered SC to rats had no effect upon mating performance; however, fertility was decreased at the highest dose (see Toxicology: Pre-clinical safety data under Actions).
Use in Pregnancy: There are limited data on the use of Dermovate in pregnant women. Topical administration of corticosteroids to pregnant animals can cause abnormalities of fetal development (see Toxicology: Pre-clinical safety data under Actions).
The relevance of this finding to humans has not been established. Administration of Dermovate during pregnancy should only be considered if the expected benefit to the mother outweighs the risk to the fetus. The minimum quantity should be used for the minimum duration.
Use in Lactation: The safe use of topical corticosteroids during lactation has not been established.
It is not known whether the topical administration of corticosteroids could result in sufficient systemic absorption to produce detectable amounts in breast milk. Administration of Dermovate during lactation should only be considered if the expected benefit to the mother outweighs the risk to the infant.
If used during lactation, Dermovate should not be applied to the breasts to avoid accidental ingestion by the infant.
Use in Pregnancy: There are limited data on the use of Dermovate in pregnant women. Topical administration of corticosteroids to pregnant animals can cause abnormalities of fetal development (see Toxicology: Pre-clinical safety data under Actions).
The relevance of this finding to humans has not been established. Administration of Dermovate during pregnancy should only be considered if the expected benefit to the mother outweighs the risk to the fetus. The minimum quantity should be used for the minimum duration.
Use in Lactation: The safe use of topical corticosteroids during lactation has not been established.
It is not known whether the topical administration of corticosteroids could result in sufficient systemic absorption to produce detectable amounts in breast milk. Administration of Dermovate during lactation should only be considered if the expected benefit to the mother outweighs the risk to the infant.
If used during lactation, Dermovate should not be applied to the breasts to avoid accidental ingestion by the infant.
Adverse Reactions
Adverse drug reactions are listed as follows by MedDRA system organ class and by frequency. Frequencies are defined as: Very common (≥1/10), common (≥1/100 and <1/10), uncommon (≥1/1000 and <1/100), rare (≥1/10,000 and <1/1000) and very rare (<1/10,000), including isolated reports.
Post-Marketing Data: Infections and Infestations: Very rare: Opportunistic infection.
Immune System Disorders: Very rare: Local hypersensitivity.
Endocrine Disorders: Very rare: Hypothalamic-pituitary-adrenal (HPA) axis suppression: Cushingoid features (eg, moon face, central obesity), delayed weight gain/growth retardation in children, osteoporosis, glaucoma, hyperglycemia/glucosuria, cataract, hypertension, increased weight/obesity, decreased endogenous cortisol levels, alopecia, trichorrhexis.
Skin and Subcutaneous Tissue Disorders: Common: Pruritus, local skin burning/skin pain. Uncommon: Skin atrophy*, striae*, telangiectasias*.
Very rare: Skin thinning*, skin wrinkling*, skin dryness*, pigmentation changes*, hypertrichosis, exacerbation of underlying symptoms, allergic contact dermatitis/dermatitis, pustular psoriasis, erythema, rash, urticaria, acne.
General Disorders and Administration Site Conditions: Very rare: Application site irritation/pain.
*Skin features secondary to local and/or systemic effects of HPA axis suppression.
Post-Marketing Data: Infections and Infestations: Very rare: Opportunistic infection.
Immune System Disorders: Very rare: Local hypersensitivity.
Endocrine Disorders: Very rare: Hypothalamic-pituitary-adrenal (HPA) axis suppression: Cushingoid features (eg, moon face, central obesity), delayed weight gain/growth retardation in children, osteoporosis, glaucoma, hyperglycemia/glucosuria, cataract, hypertension, increased weight/obesity, decreased endogenous cortisol levels, alopecia, trichorrhexis.
Skin and Subcutaneous Tissue Disorders: Common: Pruritus, local skin burning/skin pain. Uncommon: Skin atrophy*, striae*, telangiectasias*.
Very rare: Skin thinning*, skin wrinkling*, skin dryness*, pigmentation changes*, hypertrichosis, exacerbation of underlying symptoms, allergic contact dermatitis/dermatitis, pustular psoriasis, erythema, rash, urticaria, acne.
General Disorders and Administration Site Conditions: Very rare: Application site irritation/pain.
*Skin features secondary to local and/or systemic effects of HPA axis suppression.
Drug Interactions
Co-administered drugs that can inhibit CYP3A4 (eg, ritonavir and itraconazole) have been shown to inhibit the metabolism of corticosteroids leading to increased systemic exposure. The extent to which this interaction is clinically relevant depends on the dose and route of administration of the corticosteroids and the potency of the CYP3A4 inhibitor.
Storage
Store at temperatures not exceeding 30°C.
Action
Pharmacotherapeutic Group: Corticosteroids, very potent (group IV). ATC Code: D07AD.
Pharmacology: Mechanism of Action: Topical corticosteroids act as anti-inflammatory agents via multiple mechanisms to inhibit late phase allergic reactions including decreasing the density of mast cells, decreasing chemotaxis and activation of eosinophils, decreasing cytokine production by lymphocytes, monocytes, mast cells and eosinophils, and inhibiting the metabolism of arachidonic acid.
Pharmacodynamic Effects: Topical corticosteroids have anti-inflammatory, antipruritic and vasoconstrictive properties.
Pharmacokinetics: Absorption: Topical corticosteroids can be systemically absorbed from intact healthy skin. The extent of percutaneous absorption of topical corticosteroids is determined by many factors, including the vehicle and the integrity of the epidermal barrier. Occlusion, inflammation and/or other disease processes in the skin may also increase percutaneous absorption.
Mean peak plasma clobetasol propionate concentrations of 0.63 nanogram/mL occurred in 1 study 8 hrs after the 2nd application (13 hrs after an initial application) of 30 g clobetasol propionate 0.05% ointment to normal individuals with healthy skin. Following the application of a 2nd dose of 30 g clobetasol propionate 0.05% cream, mean peak plasma concentrations were slightly higher than the ointment and occurred 10 hrs after application. In a separate study, mean peak plasma concentrations of approximately 2.3 and 4.6 nanogram/mL occurred in patients with psoriasis and eczema, respectively, 3 hrs after a single application of 25 g clobetasol propionate 0.05% ointment.
Distribution: The use of pharmacodynamic endpoints for assessing the systemic exposure of topical corticosteroids is necessary due to the fact that circulating levels are well below the level of detection.
Metabolism: Once absorbed through the skin, topical corticosteroids are handled through pharmacokinetic pathways similar to systemically administered corticosteroids. They are metabolized primarily in the liver.
Elimination: Topical corticosteroids are excreted by the kidneys. In addition, some corticosteroids and their metabolites are also excreted in the bile.
Toxicology: Preclinical Safety Data: Carcinogenesis: Long-term animal studies have not been performed to evaluate the carcinogenic potential of clobetasol propionate.
Genotoxicity: Clobetasol propionate was not mutagenic in a range of in vitro bacterial cell assays.
Fertility: In fertility studies, SC administration of clobetasol propionate to rats at doses of 6.25-50 mcg/kg/day produced no effects on mating, and fertility was only decreased at 50 mcg/kg/day.
Pregnancy: SC administration of clobetasol propionate to mice (≥100 mcg/kg/day), rats (400 mcg/kg/day) or rabbits (1-10 mcg/kg/day) during pregnancy produced fetal abnormalities including cleft palate.
In the rat study, where some animals were allowed to litter, developmental delay was observed in the F1 generation at ≥100 mcg/kg/day and survival was reduced at 400 mcg/kg/day. No treatment-related effects were observed in F1 reproductive performance or in the F2 generation.
Pharmacology: Mechanism of Action: Topical corticosteroids act as anti-inflammatory agents via multiple mechanisms to inhibit late phase allergic reactions including decreasing the density of mast cells, decreasing chemotaxis and activation of eosinophils, decreasing cytokine production by lymphocytes, monocytes, mast cells and eosinophils, and inhibiting the metabolism of arachidonic acid.
Pharmacodynamic Effects: Topical corticosteroids have anti-inflammatory, antipruritic and vasoconstrictive properties.
Pharmacokinetics: Absorption: Topical corticosteroids can be systemically absorbed from intact healthy skin. The extent of percutaneous absorption of topical corticosteroids is determined by many factors, including the vehicle and the integrity of the epidermal barrier. Occlusion, inflammation and/or other disease processes in the skin may also increase percutaneous absorption.
Mean peak plasma clobetasol propionate concentrations of 0.63 nanogram/mL occurred in 1 study 8 hrs after the 2nd application (13 hrs after an initial application) of 30 g clobetasol propionate 0.05% ointment to normal individuals with healthy skin. Following the application of a 2nd dose of 30 g clobetasol propionate 0.05% cream, mean peak plasma concentrations were slightly higher than the ointment and occurred 10 hrs after application. In a separate study, mean peak plasma concentrations of approximately 2.3 and 4.6 nanogram/mL occurred in patients with psoriasis and eczema, respectively, 3 hrs after a single application of 25 g clobetasol propionate 0.05% ointment.
Distribution: The use of pharmacodynamic endpoints for assessing the systemic exposure of topical corticosteroids is necessary due to the fact that circulating levels are well below the level of detection.
Metabolism: Once absorbed through the skin, topical corticosteroids are handled through pharmacokinetic pathways similar to systemically administered corticosteroids. They are metabolized primarily in the liver.
Elimination: Topical corticosteroids are excreted by the kidneys. In addition, some corticosteroids and their metabolites are also excreted in the bile.
Toxicology: Preclinical Safety Data: Carcinogenesis: Long-term animal studies have not been performed to evaluate the carcinogenic potential of clobetasol propionate.
Genotoxicity: Clobetasol propionate was not mutagenic in a range of in vitro bacterial cell assays.
Fertility: In fertility studies, SC administration of clobetasol propionate to rats at doses of 6.25-50 mcg/kg/day produced no effects on mating, and fertility was only decreased at 50 mcg/kg/day.
Pregnancy: SC administration of clobetasol propionate to mice (≥100 mcg/kg/day), rats (400 mcg/kg/day) or rabbits (1-10 mcg/kg/day) during pregnancy produced fetal abnormalities including cleft palate.
In the rat study, where some animals were allowed to litter, developmental delay was observed in the F1 generation at ≥100 mcg/kg/day and survival was reduced at 400 mcg/kg/day. No treatment-related effects were observed in F1 reproductive performance or in the F2 generation.
MedsGo Class
Topical Corticosteroids
Features
Brand
Dermovate
GTIN
4800333160824
Full Details
Dosage Strength
500mcg / g
Drug Ingredients
- Clobetasol
Drug Packaging
Cream 5g
Generic Name
Clobetasol Propionate
Dosage Form
Cream
Registration Number
DR-10074
Drug Classification
Prescription Drug (RX)