Provider Briefing: Mestinon Supply Disruption

If your patients are reporting difficulty filling Pyridostigmine Bromide prescriptions — particularly the extended-release 180 mg formulation — you're seeing the effects of a supply disruption that has been building since mid-2024. This briefing covers the current state of Mestinon availability, what it means for your prescribing decisions, and tools you can share with patients to help them locate medication.

Timeline of the Shortage

The supply issues with Pyridostigmine have followed a gradual trajectory:

• Early 2024: Patients and pharmacists began reporting spot shortages of Pyridostigmine ER 180 mg tablets at retail pharmacies
• Mid-2024: Reports became widespread. Major chains including CVS, Walgreens, and Walmart reported inability to source the ER formulation from their primary wholesalers
• Late 2024 – Early 2025: Generic manufacturers Alvogen and Rising Pharmaceuticals confirmed back orders on Pyridostigmine ER 180 mg with no estimated release date. The shortage was not formally listed on the FDA drug shortage database
• 2025 – 2026: The ER shortage persists. Bausch Health's brand-name Mestinon Timespan remains available but at significantly higher cost. The immediate-release 60 mg tablets and oral solution have been relatively unaffected

Prescribing Implications

The supply disruption creates several clinical considerations:

Formulation Switching

For patients who cannot find Pyridostigmine ER 180 mg, the most straightforward intervention is switching to the immediate-release 60 mg tablets. The active ingredient is identical; only the release profile differs. Key considerations:

• A patient on 180 mg ER twice daily would need approximately 60 mg IR every 4–6 hours (total daily dose of 360–540 mg)
• The IR formulation requires more frequent dosing, which may affect adherence
• Peak-and-trough fluctuations may be more noticeable with IR dosing
• The ER formulation is often preferred at bedtime for overnight symptom control; patients switching to IR may need a dose timed for overnight coverage

Dose Optimization

This is also an opportunity to reassess whether your patient's current dose is optimized. Some patients may be on higher doses than necessary, and a gradual dose reduction trial (under supervision) could reduce their total Pyridostigmine requirement.

Off-Label Prescribing Volume

A significant contributor to supply pressure is the growing off-label use of Pyridostigmine for POTS, neurogenic orthostatic hypotension, Long COVID autonomic dysfunction, and ME/CFS. While these are legitimate clinical uses supported by emerging evidence, the expanded patient population has strained a supply chain built around myasthenia gravis demand alone.

When prescribing off-label, consider whether the patient has tried other first-line interventions (e.g., volume expansion, compression garments, exercise therapy for POTS) before adding Pyridostigmine.

Current Availability Picture

As of early 2026, the availability landscape looks like this:

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

Cost and Access Considerations

Cost is a significant barrier for many patients, especially when generic ER is unavailable and the brand alternative is expensive:

• Generic IR 60 mg (90 tablets): $26–$50 with discount cards (GoodRx, SingleCare)
• Generic ER 180 mg (30 tablets): $105–$150 with discount cards when available; $700+ retail
• Brand Mestinon Timespan: $800+ without insurance

For uninsured or underinsured patients, Bausch Health offers a Patient Assistance Program (bauschhealthpap.com) that can provide brand-name Mestinon at no cost to qualifying individuals. Additional resources include NeedyMeds (needymeds.org) and RxAssist (rxassist.org).

Insurance coverage for generic Pyridostigmine is typically straightforward — most plans cover the IR formulation without prior authorization. The ER formulation may require prior authorization or step therapy documentation.

Tools and Resources for Your Practice

Here are practical tools you can use or share with patients:

• Medfinder for Providers: Real-time pharmacy stock checker. Direct patients here — or use it yourself — to find which nearby pharmacies have Pyridostigmine in stock
• Compounding pharmacies: For patients who need custom doses or when commercial formulations are unavailable
• Mail-order pharmacies: Express Scripts, CVS Caremark, and Amazon Pharmacy may have stock when local pharmacies don't
• Bausch Health PAP: bauschhealthpap.com for uninsured patients needing brand-name Mestinon

For a step-by-step workflow you can integrate into your practice, see our provider's guide to helping patients find Mestinon.

Alternative Therapies to Consider

When Pyridostigmine is unavailable and formulation switching isn't sufficient, consider these alternatives based on the patient's underlying condition:

For Myasthenia Gravis

• Neostigmine (Prostigmin): Same drug class, shorter duration, more GI and cardiac side effects
• Azathioprine (Imuran): Immunosuppressant; steroid-sparing; onset in weeks to months
• Mycophenolate Mofetil (CellCept): Alternative immunosuppressant for Azathioprine-intolerant patients
• Complement inhibitors (Ultomiris, Soliris) and FcRn inhibitors (Vyvgart): For refractory generalized MG

For POTS / Autonomic Dysfunction

• Midodrine: Alpha-1 agonist for orthostatic hypotension
• Fludrocortisone: Mineralocorticoid for volume expansion
• Ivabradine: Heart rate reduction without blood pressure effects
• Non-pharmacologic measures: Increased salt and fluid intake, compression garments, graded exercise

Looking Ahead

The Pyridostigmine supply situation is unlikely to resolve quickly given the limited number of generic manufacturers and continued growth in off-label demand. Providers should:

1. Proactively discuss backup plans with patients who depend on Pyridostigmine
2. Consider prescribing the IR formulation when possible, as it has a more stable supply
3. Document clinical rationale thoroughly when prescribing brand-name Mestinon Timespan, as insurance companies may require justification
4. Stay current on FDA shortage notifications at accessdata.fda.gov/scripts/drugshortages

Final Thoughts

The Mestinon shortage is a supply-side problem with real clinical consequences. By staying informed, adjusting prescribing strategies where appropriate, and leveraging tools like Medfinder for Providers, you can help your patients maintain continuity of care during this challenging period.

For the patient-facing version of this update, share our Mestinon shortage guide for patients. For cost-saving strategies, see our provider's guide to helping patients save money on Mestinon.