Your Patients Can't Find Mestinon — Here's How You Can Help

When a patient calls your office saying they can't fill their Pyridostigmine Bromide prescription, it creates a clinical problem that goes beyond the pharmacy counter. For myasthenia gravis patients, gaps in Mestinon therapy can lead to rapid symptom worsening — including difficulty swallowing, breathing, and performing basic daily activities. For POTS and autonomic dysfunction patients, going without can mean debilitating fatigue, tachycardia, and syncope.

As a prescriber, you have more levers to pull than patients realize. This guide walks you through a practical, five-step approach to helping your patients access Mestinon during the current supply disruption.

Current Availability Overview

Understanding what's available — and what isn't — is the first step:

• Pyridostigmine IR 60 mg tablets (generic): Generally available at most pharmacies nationwide
• Pyridostigmine ER 180 mg tablets (generic): Back ordered from major generic manufacturers (Alvogen, Rising); limited and unpredictable availability
• Mestinon Timespan 180 mg (brand, Bausch Health): Available but expensive (~$800+ without insurance)
• Mestinon Syrup 60 mg/5 mL: Generally available

The bottom line: the ER formulation is the problem. If your patient needs ER specifically, they'll need more help finding it. If IR is clinically acceptable, the search becomes much easier.

Why Patients Can't Find Mestinon

Several interconnected factors are creating the access problem:

1. Manufacturing back orders: With Alvogen and Rising both unable to supply Pyridostigmine ER, only Bausch Health's brand product remains consistently available
2. Wholesaler limitations: Chain pharmacies often source from a single wholesaler, so when that wholesaler is out, the entire chain is affected
3. Demand growth: Off-label prescribing for POTS, Long COVID, and related conditions has substantially increased total Pyridostigmine demand
4. Patient awareness gaps: Many patients don't know about tools like Medfinder, independent pharmacies, or mail-order options

What Providers Can Do: 5 Steps

Step 1: Assess Formulation Flexibility

Before anything else, determine whether your patient must have the ER formulation or whether the IR version would be clinically appropriate.

• The IR 60 mg tablet is the same active ingredient with a shorter duration of action
• A patient on 180 mg ER BID can transition to 60 mg IR every 4–6 hours
• The IR formulation is significantly easier to find and much less expensive
• For patients who use ER primarily for overnight coverage, a dose of IR at bedtime plus one during the night may provide acceptable symptom control

If switching to IR is viable, this alone often solves the problem.

Step 2: Direct Patients to Medfinder

Medfinder for Providers is a real-time pharmacy stock checker that shows which pharmacies near a given zip code currently have Pyridostigmine available. You can:

• Look up availability during the appointment and give patients a specific pharmacy to try
• Share the link (medfinder.com) with patients so they can check on their own
• Use it to verify stock before sending a new prescription to a specific pharmacy

This is the single most efficient way to match patients with available supply.

Step 3: Recommend Independent and Mail-Order Pharmacies

If chain pharmacies are out, two channels often still have stock:

Independent pharmacies:

• Use different wholesalers than chains (often regional distributors)
• May have compounding capabilities for custom Pyridostigmine preparations
• Are typically more willing to search multiple suppliers for a patient

Mail-order pharmacies:

• Express Scripts, CVS Caremark, OptumRx, and Amazon Pharmacy source from national distributors
• Often have larger inventories and can fill prescriptions that local pharmacies cannot
• Many insurance plans offer lower copays for mail-order

Step 4: Facilitate Prior Authorization for Brand-Name Mestinon

When generic ER is unavailable, brand-name Mestinon Timespan from Bausch Health may be the only ER option. To help patients access it:

• Document that generic ER is unavailable (back order confirmation from the pharmacy is helpful)
• Submit a prior authorization to the patient's insurance with medical necessity documentation
• Note the shortage as justification — many insurers have shortage override policies
• For uninsured patients, refer to Bausch Health's Patient Assistance Program at bauschhealthpap.com

Step 5: Have a Backup Plan Ready

For patients whose Mestinon supply is precarious, proactively discuss alternatives:

• Neostigmine (Prostigmin): Same class, shorter acting, available in oral form
• Immunosuppressants (Azathioprine, Mycophenolate): For MG patients, may reduce Pyridostigmine dependence over time
• POTS-specific alternatives: Midodrine, Fludrocortisone, Ivabradine

For a comprehensive overview of alternatives, see alternatives to Mestinon.

Workflow Tips for Your Practice

Here are ways to systematize Mestinon access support:

• Flag Pyridostigmine patients in your EHR so staff can proactively check availability before appointments
• Keep a list of independent pharmacies in your area that stock Pyridostigmine — call and confirm quarterly
• Pre-authorize brand-name Mestinon for patients with a history of generic access problems
• Educate patients about early refills — encourage them to refill 7–10 days before running out
• Provide partial fill guidance — patients may not know they can ask pharmacies to dispense what's available and fill the balance later
• Share Medfinder — add medfinder.com/providers to your patient handout materials

Final Thoughts

The Mestinon shortage puts providers in a difficult position, but you have more tools at your disposal than you might think. By proactively assessing formulation flexibility, leveraging real-time stock tools, and having backup plans in place, you can help ensure your patients don't face dangerous gaps in their Pyridostigmine therapy.

For the clinical details on the shortage itself, see our provider briefing on the Mestinon shortage. For cost and savings guidance to share with patients, see how to help patients save money on Mestinon.