Provider Briefing: Mannitol Supply Remains Constrained in 2026

The Mannitol injection shortage continues to challenge hospitals, emergency departments, and critical care units across the United States. As a provider, you're likely already managing the downstream effects of this shortage — but having a clear picture of the current landscape can help you make better-informed clinical and logistical decisions.

This briefing covers the current supply status, shortage timeline, prescribing implications, alternative agents, cost considerations, and tools to help you and your patients navigate the situation.

Shortage Timeline

The Mannitol IV shortage has followed a trajectory common to many IV fluid shortages — slow onset, extended duration, and no clear resolution date:

• 2014–2022: Intermittent spot shortages of Mannitol IV reported, primarily related to manufacturing transitions as Hospira's IV business was acquired by Pfizer and subsequently by ICU Medical
• 2023: ICU Medical placed Mannitol 20% (200 mg/mL) premixed bags on formal allocation. ASHP added Mannitol injection to the active shortage list
• 2024–2025: Allocation continued with no meaningful improvement. Broader IV fluid supply chain disruptions compounded the problem
• 2026 (current): ICU Medical Mannitol 20% 250 mL and 500 mL premixed bags remain on allocation. No new manufacturers have entered the market. ASHP shortage listing remains active (last updated August 2025)

The fundamental issue is concentrated manufacturing capacity. With ICU Medical as the dominant domestic supplier, any production constraint creates a national shortage with no rapid path to recovery.

Prescribing Implications

The ongoing shortage has several practical implications for prescribers:

Formulary Restrictions

Many hospital pharmacy and therapeutics (P&T) committees have implemented Mannitol conservation protocols, including:

• Restricting Mannitol to specific indications (e.g., acute intracranial hypertension refractory to first-line measures)
• Requiring pharmacist or intensivist approval before dispensing
• Setting dose caps or duration limits
• Prioritizing Mannitol for neurosurgical and neuro-ICU patients

Clinical Decision-Making

Providers should consider whether Mannitol is truly the optimal agent for each clinical scenario, or whether an alternative would serve equally well:

• For intracranial pressure management, current evidence supports Hypertonic Saline as a first-line alternative with comparable or superior efficacy
• For intraocular pressure reduction, Acetazolamide (oral or IV) and topical agents should be maximized before resorting to IV osmotic therapy
• For renal protection during cardiac surgery, the evidence for Mannitol is limited, and many centers have moved away from routine use

Documentation

Given allocation constraints, thorough documentation of clinical indication and rationale for Mannitol use is increasingly important for pharmacy dispensing and quality review.

Current Availability Picture

As of February 2026:

• ICU Medical Mannitol 20% 250 mL premixed bags: On allocation — limited supply
• ICU Medical Mannitol 20% 500 mL premixed bags: On allocation — limited supply
• Mannitol 25% vials (various): Intermittently available from secondary suppliers
• Compounded Mannitol: Available from some 503B outsourcing facilities, though quality and consistency vary
• Bronchitol (inhaled): Separately manufactured and distributed; not affected by the IV shortage

Facilities should monitor Medfinder for Providers for real-time supply tracking and consider establishing relationships with multiple wholesalers and compounding partners.

Cost and Access Considerations

While Mannitol IV is relatively inexpensive on a per-unit basis ($12–$60 per bag depending on volume and concentration), the shortage has created secondary market dynamics:

• Some facilities report paying premium prices from secondary distributors during acute supply gaps
• Compounded alternatives may carry higher per-unit costs plus shipping and handling fees
• For patients receiving Bronchitol, the cost burden is significant: approximately $3,826/month without insurance, though Chiesi's CareConnect program can help eligible patients

Insurance coverage for IV Mannitol is generally not an issue, as it's billed as part of facility charges. However, outpatient or ambulatory surgical center billing may vary.

Tools and Resources for Providers

Several resources can help you manage the Mannitol shortage more effectively:

• Medfinder for Providers — Real-time medication availability tracking designed for clinical teams. Search for Mannitol to see current stock status across suppliers.
• ASHP Drug Shortage Resource Center — Maintains the official Mannitol shortage listing with manufacturer updates and conservation recommendations
• Your health system's drug shortage committee — Most hospitals have formal processes for managing shortages; ensure you're connected to their communications

For patient-facing resources you can share:

• Mannitol Shortage Update for Patients
• Alternatives to Mannitol
• What Is Mannitol? Patient Guide

Alternative Agents: Clinical Summary

The following alternatives are supported by clinical evidence and may be used when Mannitol is unavailable or when clinical circumstances favor their use:

Hypertonic Saline (3%, 7.5%, 23.4%)

• Indication: Intracranial pressure reduction
• Evidence: Multiple meta-analyses demonstrate non-inferiority or superiority to Mannitol for ICP reduction in traumatic and non-traumatic brain injury
• Advantages: Does not require intact renal function; may be preferred in hypovolemic or hypotensive patients; does not cause osmotic diuresis
• Monitoring: Serum sodium (target typically <160 mEq/L), serum osmolality
• Caution: Central line preferred for concentrations >3%; risk of central pontine myelinolysis with rapid sodium correction

Furosemide (Lasix)

• Indication: Adjunctive diuresis, fluid overload
• Role: Complementary rather than direct replacement; may be combined with Hypertonic Saline
• Note: Does not provide osmotic ICP reduction; mechanism is purely diuretic

Acetazolamide (Diamox)

• Indication: Intraocular pressure reduction, idiopathic intracranial hypertension
• Role: Useful alternative for IOP reduction when Mannitol is unavailable; reduces CSF production
• Available: Oral and IV formulations

Glycerol

• Indication: ICP and IOP reduction (less commonly used)
• Role: Third-line osmotic agent; may cause hyperglycemia
• Note: Limited current clinical use in the U.S.

Looking Ahead

The Mannitol shortage is unlikely to resolve quickly. The structural factors driving it — concentrated manufacturing, complex sterile production requirements, and rising demand — will take time to address. Providers should:

• Develop and maintain institutional protocols for Mannitol alternatives
• Ensure Hypertonic Saline protocols are established and staff are trained
• Monitor supply through Medfinder for Providers and ASHP
• Educate patients proactively about the shortage and alternative treatment plans

Final Thoughts

The Mannitol shortage requires clinical flexibility and proactive supply management. The evidence base for alternatives — particularly Hypertonic Saline — is strong, and most patients can be effectively managed even when Mannitol is unavailable. The key is preparation: having protocols in place, knowing your alternatives, and staying informed about supply changes.

Visit Medfinder for Providers to track Mannitol availability in real time, and share our provider's guide to helping patients find Mannitol with your clinical team.