Reply to a letter written by a local prescriber by considering the clinical issue of patient and using an academic writing (UK style). Use BNF, SPCs on medicines.org.uk, national guidance and medical journals as reference. (at least 2 pages) Dear Pharmacist, Can you help me treat my patient, Ms. RH, who is 78 years old. She came to clinic for relief of a chest infection yesterday but has subsequently informed me that she is going out of the area for some time. I am currently treating her atrial fibrillation with Warfarin, however, she does not wish to continue on this treatment due to the monitoring constraints. She has had erratic INRs over the last few months so is being monitored on a weekly basis. Last INR reading was taken yesterday and was 3.2 (target of 2.5). She also suffers from stage 3 CKD, she has had a stroke in the past and has mild hypertension and No Known Drug Allergies. Current medicines: Zocor 40mg on Warfarin od as per INR Lansoprazole 30mg om Amlodipine 10mg om Ramipril 7.5mg om Ferrous sulphate 200mg TDS Sodium Bicarbonate 500mg TDS Augmentin 625mg TDS 1/52 Clarithromycin 500mg bd 1/52 I am looking for your advice regarding which anticoagulant would be most appropriate for this patient and when is safest to initiate treatment. Dr Matt