Editing ASRA cease and desist against CoagRef

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<!-- MODIFIED SECTIONS: Background; ASRA Coags subscription transition; CoagRef and the cease-and-desist; Copyright and publicly published safety standards; Physician and community response; Patient-safety stakes; References -->
{{IncidentCargo
|IncidentName=ASRA cease and desist against CoagRef
|Company=American Society of Regional Anesthesia and Pain Medicine
|StartDate=2026-05-15
|EndDate=
|Categories=Standards monopolization; Subscription bait-and-switch; App Store takedown; Medical-sector consumer rights
|Description=Free physician-built iOS reference app CoagRef was removed in May 2026 after legal demands from a large anesthesiology organization over guideline content.
}}

'''ASRA cease and desist against CoagRef''' refers to the May 2026 removal of '''CoagRef''', a free iOS clinical reference app written by Houston-based cardiothoracic anesthesiologist Rishi Kumar, MD, after he received legal demands from lawyers representing what he described as "a large organization in anesthesiology."<ref name="kumar-fb" /> The only anesthesiology organization that publishes Coags-branded reference software based on the underlying anticoagulation guidelines is the American Society of Regional Anesthesia and Pain Medicine (ASRA), whose own ASRA Coags app was converted in April 2025 from a one-time $3.99 purchase to a $6.99 annual subscription that locked out prior buyers.<ref name="appstore-wayback-2024" /><ref name="appstore-current" /> The underlying guidelines that both apps summarize are published under the "Free" access tier at the BMJ journal ''Regional Anesthesia & Pain Medicine''.<ref name="rapm-horlocker-2018" /><ref name="rapm-kopp-2025" />

== Background ==

ASRA publishes the canonical evidence-based guidelines used in North America for timing regional anesthesia procedures (spinal and epidural blocks, nerve blocks, interventional pain injections) in patients on anticoagulant or antiplatelet medications. The fourth edition was published in 2018 as Horlocker et al., ''Regional Anesthesia in the Patient Receiving Antithrombotic or Thrombolytic Therapy: American Society of Regional Anesthesia and Pain Medicine Evidence-Based Guidelines (Fourth Edition)'' in ''Regional Anesthesia & Pain Medicine'' 43(3):263-309.<ref name="rapm-horlocker-2018" /> The fifth edition, by Kopp et al., was published online ahead of print on October 16, 2025.<ref name="rapm-kopp-2025" /> Both editions are hosted at rapm.bmj.com under the "FREE" designation, meaning anonymous visitors can download the full PDF without a subscription.<ref name="rapm-horlocker-2018" /><ref name="rapm-kopp-2025" /> Both editions remain under standard copyright; the BMJ page footer states that "All rights, including for text and data mining, AI training, and similar technologies, are reserved," and reuse requires permission via the Copyright Clearance Center.<ref name="rapm-horlocker-2018" /><ref name="rapm-kopp-2025" />

The guidelines are clinically load-bearing. The recommended interruption times between a drug dose and a neuraxial procedure are the principal defense against spinal epidural hematoma, a rare but catastrophic complication that can cause permanent paralysis if hemorrhage compresses the spinal cord and is not surgically decompressed in time.<ref name="nysora-hematoma" /> Quoted incidence estimates range from approximately 1 in 200,000 spinal blocks and 1 in 150,000 epidural blocks in unselected patients, to as frequent as 1 in 3,600 or 1 in 1,000 in some elderly surgical cohorts.<ref name="southern-pain" /><ref name="nysora-hematoma" />

ASRA has distributed a mobile reference app, '''ASRA Coags''', since at least 2014. The app, developed at Vanderbilt University Medical Center under Rajnish Gupta, MD and Matthew McEvoy, MD with code by Mustard Seed Software, LLC, converts the guideline tables into a drug-by-drug lookup keyed to block type, catheter removal, and bleeding risk.<ref name="appstore-wayback-2024" /> A December 14, 2024 Wayback Machine capture of the Apple App Store listing shows the app priced at a one-time $3.99 with no subscription component.<ref name="appstore-wayback-2024" />

== ASRA Coags subscription transition ==

On April 21, 2025, ASRA shipped version 4.0 of ASRA Coags. The current App Store listing's version history records the v4.0 update only as "Update the ui and contents", with no disclosure in the release notes that the app would now require an annual subscription.<ref name="appstore-current" /> Within days, prior purchasers began reporting that the app had locked them out of the content they had previously paid for and now required a $6.99 annual subscription, or membership in ASRA Pain Medicine, to access.<ref name="sdn-1508690" /> The Apple App Store listing's current description states the change directly:

<blockquote>''The ASRA COAGS app has been updated with a universal code base and a fresh new look. This subscription-based app is $6.99/annually or free with ASRA Pain Medicine membership.''</blockquote><ref name="appstore-current" />

ASRA's own apps page at asra.com confirms identical pricing: "Subscription-based app: $6.99/annually or free with ASRA Pain Medicine membership."<ref name="asra-apps-page" /> Subsequent version updates kept the subscription model in place: v5.0 on July 7, 2025 ("Implemented new features & UI work"), v5.1 on September 9, 2025, and v6.1 on December 3, 2025.<ref name="appstore-current" />

Prior one-time purchasers were not grandfathered. On May 1, 2025, a Student Doctor Network thread titled "ASRA Coags App now Membership Only" was opened by user TeslaCoil, who wrote that the previously paid app no longer functioned without a new account and subscription.<ref name="sdn-1508690" /> Other posters in the same thread reported emailing ASRA support directly and, in some cases, asking for refunds: one wrote, "Also I emailed ASRA about my annoyance and asked for my money back, as my paid for app was no longer functional. They offered me a year free."<ref name="sdn-1508690" /> Another wrote, "I made them send me a refund for the app on principle alone."<ref name="sdn-1508690" /> A second thread opened by user Baron S on July 21, 2025, titled "ASRA Coag App subscription," documented the same complaint two months later. Baron S wrote on the Student Doctor Network forums:

<blockquote>''Despite the fact that many providers rely on this for patient safety and have already paid for the app, ASRA has now made the Coag app a subscription model $6.99/annually. This change happened a couple months ago and they appear to be sticking with it despite the backlash.''</blockquote><ref name="sdn-1511800" />

App Store reviews corroborate the same pattern with named, dated entries. Reviewer DD, MD wrote on the App Store on May 9, 2025:

<blockquote>''Predatory business practice for an organization as well regarded as ASRA to now mandate a yearly paid subscription for an app that many of us originally paid for lifetime access.''</blockquote><ref name="appstore-current" />

Reviewer Kypdurron5 wrote on the App Store on May 18, 2025:

<blockquote>''ASRA has made a declaration by locking clinicians out of an app they already paid for until they now also pay a subscription fee.''</blockquote><ref name="appstore-current" />

Reviewer Blahghg wrote on the App Store on June 12, 2025:

<blockquote>''I paid for this app (one time fee) and now they are charging a yearly subscription fee to use it. This is a bait and switch.''</blockquote><ref name="appstore-current" />

The app's overall App Store rating sat at 1.3 stars across 391 ratings as of the May 2026 capture.<ref name="appstore-current" />

== CoagRef and the cease-and-desist ==

CoagRef was a free iOS application authored by Rishi Kumar, MD, a Harvard-trained cardiothoracic anesthesiologist and cardiovascular intensive care physician practicing in the Texas Medical Center.<ref name="rkmd-about" /> Kumar publishes a suite of free, no-registration, no-subscription medical reference apps (EBMRef, ECGRef, EchoRef, LabRef, VentRef) at rkref.app.<ref name="rkmd-about" /> CoagRef summarized the same anticoagulation timing recommendations that ASRA Coags covered, drawn from the publicly downloadable BMJ guideline PDFs.

On or about May 15, 2026, Kumar announced on his public Facebook page (facebook.com/rishikumarmd) that he was pulling CoagRef from distribution. Capture metadata shows the post was retrieved on May 18, 2026 and dated "3d" in the Facebook interface, placing publication at approximately May 15, 2026; the post had accumulated 93 reactions and 7 comments.<ref name="kumar-fb" /> In a May 15, 2026 Facebook post, Kumar wrote, in part:

<blockquote>''CoagRef is being removed from my websites and Apple's App Store as I comply with the demands outlined by lawyers for a large organization in anesthesiology. Apparently, information that's freely available as a PDF cannot be cited and used in a free application without their terms. Farewell, CoagRef! This reflects a broader, growing problem in medicine, where education, accessibility, and innovation increasingly collide with corporate interests and territorialism. We should be making high-quality medical knowledge easier to access, not harder. What happened to patient care and safety >>> profit?''</blockquote><ref name="kumar-fb" />

Kumar's statement does not name ASRA. The only organization in anesthesiology that publishes a competing Coags-branded reference app whose underlying anticoagulation guidelines drive both apps is ASRA, and the public record makes that linkage circumstantial rather than confirmed by the developer. As of the article's capture date, the App Store listing for CoagRef (apps.apple.com/us/app/coagref/id1462215262) returns a 404 "The page you're looking for can't be found" error, confirming the takedown.<ref name="coagref-404" />

== Copyright and publicly published safety standards ==

In ''American Society for Testing and Materials v. Public.Resource.Org, Inc.'', 82 F.4th 1262 (D.C. Cir. 2023), the D.C. Circuit held that non-commercial dissemination of privately developed technical standards that have been incorporated by reference into law constitutes fair use.<ref name="copyright-gov-fairuse" /> The decision was specific to standards incorporated by reference into law; the ASRA anticoagulation guidelines are not statutorily incorporated.

The earlier Ninth Circuit decision in ''Practice Management Information Corp. v. American Medical Association'', 121 F.3d 516 (9th Cir. 1997), recognized copyright misuse as an equitable defense that precludes enforcement of a copyright during the misuse period without invalidating the copyright itself.<ref name="ce9-jury" />

== ASRA's response ==

ASRA has not publicly addressed the CoagRef takedown. The society's own apps page at asra.com/guidelines-articles/asra-apps lists ASRA Coags and the subscription pricing but contains no statement about CoagRef or about cease-and-desist activity directed at third-party apps.<ref name="asra-apps-page" /> No press release, member email, or asra.com news article naming CoagRef was located in the research record. Trade press in anesthesiology (Anesthesiology News, ASA Monitor, MedPage Today, STAT) had not covered either the CoagRef takedown or the ASRA Coags subscription transition as of May 2026.

== Physician and community response ==

The two Student Doctor Network threads cited above remain the principal forum-side documentation of physician dissatisfaction with the ASRA Coags subscription transition. Posts in the May 1, 2025 thread describe deleting the app, switching to non-ASRA reference materials, and not renewing ASRA Pain Medicine membership over the issue.<ref name="sdn-1508690" /> The July 21, 2025 thread documents the persistence of the policy "despite the backlash."<ref name="sdn-1511800" />

App Store reviews drove the listing's rating to 1.3 stars across 391 ratings, with the recent text reviews dominated by complaints about the one-time-purchase-to-subscription transition rather than the app's clinical content.<ref name="appstore-current" /> Among peer medical societies, the American Society of Hematology publishes its clinical practice guidelines at hematology.org.<ref name="ash-guidelines" /> The American College of Cardiology / American Heart Association's 2025 Acute Coronary Syndromes guideline is marked "Free Access" at ahajournals.org.<ref name="aha-acs-2025" />

== Patient-safety stakes ==

The recommendations in the ASRA guidelines exist because the consequence of mistiming an anticoagulant relative to a neuraxial procedure is spinal epidural hematoma. The collected blood compresses the spinal cord; without urgent surgical decompression the resulting injury can be permanent. A 2018 case report in ''Clinical Practice and Cases in Emergency Medicine'' describes a 74-year-old man on rivaroxaban who developed a spontaneous spinal epidural hematoma and was found "completely paralyzed with fecal incontinence" by emergency medical services, illustrating the clinical endpoint the guidelines try to prevent.<ref name="cureus-2018" /> A 2025 peer-reviewed case in ''Clinical Case Reports'' documents a 67-year-old septic patient who developed bilateral leg paralysis requiring long-term rehabilitation from a Th6–L2 spinal epidural hematoma following accidental epidural catheter removal while coagulopathic.<ref name="pmc-2025" /> Standard incidence estimates from the Southern Pain Society educational summary place spinal epidural hematoma at roughly 1 in 200,000 after a spinal block and 1 in 150,000 after an epidural block, while a single-institution analysis at Massachusetts General Hospital found 6 confirmed cases across 43,200 epidural catheterizations, or 1 in 7,200.<ref name="southern-pain" /><ref name="mgh-epidural" />

== See also ==

* [[Click-to-cancel]]
* [[Bait-and-switch]]
* [[Brother Refresh EZ Print Subscription Service]]

== References ==

<references>
<ref name="kumar-fb">{{Cite web |url=https://www.facebook.com/rishikumarmd/posts/coagref-is-being-removed-from-my-websites-and-apples-app-store-as-i-comply-with-/1515413240212180/ |title=CoagRef is being removed from my websites and Apple's App Store as I comply with the demands outlined by lawyers for a large organization in anesthesiology |last=Kumar |first=Rishi |website=Facebook |date=2026-05-15 |access-date=2026-05-18}}</ref>
<ref name="rkmd-about">{{Cite web |url=https://rkref.app/ |title=Home - RK.MD Reference Apps |website=rkref.app |access-date=2026-05-18}}</ref>
<ref name="appstore-current">{{Cite web |url=https://apps.apple.com/us/app/asra-coags/id858796572 |title=ASRA Coags on the App Store |publisher=Apple Inc. |access-date=2026-05-18}}</ref>
<ref name="appstore-wayback-2024">{{Cite web |url=https://web.archive.org/web/20241214065922/https://apps.apple.com/us/app/asra-coags/id858796572 |title=ASRA Coags on the App Store (archived December 14, 2024) |publisher=Internet Archive Wayback Machine |date=2024-12-14 |access-date=2026-05-18}}</ref>
<ref name="asra-apps-page">{{Cite web |url=https://asra.com/guidelines-articles/asra-apps |title=ASRA Apps |publisher=American Society of Regional Anesthesia and Pain Medicine |access-date=2026-05-18}}</ref>
<ref name="coagref-404">{{Cite web |url=https://apps.apple.com/us/app/coagref/id1462215262 |title=CoagRef on the App Store (page not found) |publisher=Apple Inc. |access-date=2026-05-18}}</ref>
<ref name="rapm-horlocker-2018">{{Cite web |url=https://rapm.bmj.com/content/43/3/263 |title=Regional Anesthesia in the Patient Receiving Antithrombotic or Thrombolytic Therapy: American Society of Regional Anesthesia and Pain Medicine Evidence-Based Guidelines (Fourth Edition) |last=Horlocker |first=Terese T. |last2=Vandermeuelen |first2=Erik |last3=Kopp |first3=Sandra L. |last4=Gogarten |first4=Wiebke |last5=Leffert |first5=Lisa R. |last6=Benzon |first6=Honorio T. |date=2018 |journal=Regional Anesthesia & Pain Medicine |volume=43 |issue=3 |pages=263-309 |doi=10.1097/AAP.0000000000000763 |access-date=2026-05-18}}</ref>
<ref name="rapm-kopp-2025">{{Cite web |url=https://rapm.bmj.com/content/early/2025/10/16/rapm-2024-105766 |title=Regional anesthesia in the patient receiving antithrombotic or thrombolytic therapy: American Society of Regional Anesthesia and Pain Medicine Evidence-Based Guidelines (fifth edition) |last=Kopp |first=Sandra L. |last2=Vandermeulen |first2=Erik |last3=McBane |first3=Robert D. |last4=Perlas |first4=Anahi |last5=Leffert |first5=Lisa |last6=Horlocker |first6=Terese |date=2025-10-16 |journal=Regional Anesthesia & Pain Medicine |doi=10.1136/rapm-2024-105766 |access-date=2026-05-18}}</ref>
<ref name="sdn-1508690">{{Cite web |url=https://forums.studentdoctor.net/threads/asra-coags-app-now-membership-only.1508690/ |title=ASRA Coags App now Membership Only |first=TeslaCoil |website=Student Doctor Network Forums |date=2025-05-01 |access-date=2026-05-18}}</ref>
<ref name="sdn-1511800">{{Cite web |url=https://forums.studentdoctor.net/threads/asra-coag-app-subscription.1511800/ |title=ASRA Coag App subscription |first=Baron S |website=Student Doctor Network Forums |date=2025-07-21 |access-date=2026-05-18}}</ref>
<ref name="copyright-gov-fairuse">{{Cite web |url=https://www.copyright.gov/fair-use/summaries/amsoc-publicresourceorg-dccirc2023.pdf |title=American Society for Testing and Materials v. Public.Resource.Org, Inc., 82 F.4th 1262 (D.C. Cir. 2023): Fair Use Case Summary |publisher=United States Copyright Office |date=2023 |access-date=2026-05-18}}</ref>
<ref name="ce9-jury">{{Cite web |url=https://www.ce9.uscourts.gov/jury-instructions/node/282 |title=17.25 Copyright—Affirmative Defense—Copyright Misuse |publisher=United States Court of Appeals for the Ninth Circuit |access-date=2026-05-18}}</ref>
<ref name="nysora-hematoma">{{Cite web |url=https://www.nysora.com/topics/complications/diagnosis-management-spinal-peripheral-nerve-hematoma/ |title=Diagnosis and Management of Spinal and Peripheral Nerve Hematoma |publisher=NYSORA |access-date=2026-05-18}}</ref>
<ref name="southern-pain">{{Cite web |url=https://southernpainsociety.org/hematoma-neuraxial-pain/ |title=Hematoma Following Neuraxial Pain Procedures |publisher=Southern Pain Society |access-date=2026-05-18}}</ref>
<ref name="mgh-epidural">{{Cite web |url=https://pmc.ncbi.nlm.nih.gov/articles/PMC3799821/ |title=Epidural Catheterization in the Setting of Coagulation Abnormalities |publisher=PubMed Central |date=2010 |access-date=2026-05-18}}</ref>
<ref name="cureus-2018">{{Cite web |url=https://pmc.ncbi.nlm.nih.gov/articles/PMC5965116/ |title=Spontaneous Spinal Epidural Hematoma from Rivaroxaban |website=Clinical Practice and Cases in Emergency Medicine |publisher=UC Irvine Department of Emergency Medicine |date=2018-04-05 |access-date=2026-05-18}}</ref>
<ref name="pmc-2025">{{Cite web |url=https://pmc.ncbi.nlm.nih.gov/articles/PMC12495266/ |title=Spinal epidural hematoma following accidental epidural catheter removal in a coagulopathic septic patient |website=Clinical Case Reports |publisher=John Wiley & Sons Ltd |date=2025-10-04 |access-date=2026-05-18}}</ref>
<ref name="ash-guidelines">{{Cite web |url=https://www.hematology.org/education/clinicians/guidelines-and-quality-care/clinical-practice-guidelines |title=Clinical Practice Guidelines |publisher=American Society of Hematology |access-date=2026-05-18}}</ref>
<ref name="aha-acs-2025">{{Cite web |url=https://www.ahajournals.org/doi/10.1161/CIR.0000000000001309 |title=2025 ACC/AHA/ACEP/NAEMSP/SCAI Guideline for the Management of Patients With Acute Coronary Syndromes |publisher=American Heart Association |date=2025-02-27 |access-date=2026-05-18}}</ref>
</references>

[[Category:Incidents]]
[[Category:Medical software]]
[[Category:Subscription model controversies]]
[[Category:Copyright disputes]]
[[Category:App Store takedowns]]