always safe, there is sometimes a hesitancy to report their use which may increase the risk of adverse reaction. The following are under investigation for treatments for RA, based on preliminary promising results (not recommended for clinical use yet): boswellic acid, curcumin, devil's claw, Euonymus alatus, and thunder god vine (Tripterygium wilfordii). NCCIH has noted that, "In particular, the herb thunder god vine (Tripterygium wilfordii) can have serious side effects." There is conflicting evidence on the role of erythropoiesis-stimulating agents for treatment of anemia in persons with rheumatoid arthritis. Pregnancy More than 75% of women with rheumatoid arthritis have symptoms improve during pregnancy but might have symptoms worsen after delivery. Methotrexate and leflunomide are teratogenic (harmful to foetus) and not used in pregnancy. It is recommended women of childbearing age should use contraceptives to avoid pregnancy and to discontinue its use if pregnancy is planned. Low dose of prednisolone, hydroxychloroquine and sulfasalazine are considered safe in pregnant women with rheumatoid arthritis. Prednisolone should be used with caution as the side effects include infections and fractures. Vaccinations People with RA have an increased risk of infections and mortality and recommended vaccinations can reduce these risks. The inactivated influenza vaccine should be received annually. The pneumococcal vaccine should be administered twice for people under the age 65 and once for those over 65. Lastly, the live-attenuated zoster vaccine should be administered once after the age 60, but is not recommended in people on a tumor necrosis factor alpha blocker. Prognosis The course of the disease varies greatly. Some people have mild short-term symptoms, but in most the disease is progressive for life. Around 25% will have subcutaneous nodules (known as rheumatoid nodules); this is associated with a poor prognosis. Prognostic factors Poor prognostic factors include, Persistent synovitis Early erosive disease Extra-articular findings (including subcutaneous rheumatoid nodules) Positive serum RF findings Positive serum anti-CCP autoantibodies Positive serum 14-3-3η (YWHAH) levels above 0.5 ng/ml Carriership of HLA-DR4 "Shared Epitope" alleles Family history of RA Poor functional status Socioeconomic factors Elevated acute phase response (erythrocyte sedimentation rate [ESR], C-reactive protein [CRP]) Increased clinical severity. Mortality RA reduces lifespan on average from three to twelve years. Young age at onset, long disease duration, the presence of other health problems, and characteristics of severe RAsuch as poor functional ability or overall health status, a lot of joint damage on x-rays, the need for hospitalisation or involvement of