Midazolam Shortage: What Providers and Prescribers Need to Know in 2026

Midazolam is a cornerstone medication in procedural sedation, ICU care, emergency seizure management, and outpatient epilepsy rescue therapy. While the drug is not on the FDA's active shortage list as of early 2026, the history of midazolam supply disruptions — combined with the structural vulnerabilities of sterile injectable and specialty benzodiazepine manufacturing — means that every provider and prescriber who relies on this drug should have a contingency plan. This guide is designed to help you navigate supply challenges, communicate with patients effectively, and make evidence-based prescribing decisions when midazolam is difficult to obtain.

Current Shortage Status (2026)

As of early 2026, midazolam hydrochloride injection is not listed on the FDA's active drug shortage database or the ASHP Drug Shortages Resource Center. However, providers should be aware that:

Sterile injectable benzodiazepines as a class remain structurally vulnerable to rapid supply disruptions

Nayzilam (midazolam nasal spray, UCB) is a specialty product with a single manufacturer; retail pharmacy availability is variable

Midazolam oral syrup (2 mg/mL) is not routinely stocked at all retail pharmacies

Regional demand shifts (e.g., from a concurrent shortage of another benzodiazepine) can rapidly affect midazolam availability

Historical Shortage Context

Midazolam injectable has appeared on FDA shortage lists multiple times. The COVID-19 pandemic in 2020 dramatically increased ICU sedative demand. More recently, a shortage of IV lorazepam in 2022-2023 caused a documented surge in midazolam utilization across inpatient settings, straining supply chains for both drugs simultaneously. Providers who navigated those shortages will recognize the challenge: shortage-driven drug substitution can cascade rapidly across the benzodiazepine class.

Formulation-Specific Clinical Considerations

Injectable Midazolam (Procedural Sedation and ICU)

For procedural sedation, evidence-based alternatives when midazolam injection is unavailable include:

Propofol: Preferred by many providers for faster recovery and easier titration; less reliable amnestic effect; not a controlled substance

Lorazepam (Ativan) IV: Longer duration of action; suitable for longer procedures; also Schedule IV — note if IV lorazepam is itself in shortage

Ketamine: Used in procedural sedation, particularly in pediatrics and emergency medicine; maintains airway reflexes; dissociative rather than amnestic mechanism; Schedule III

For ICU sedation, current SCCM guidelines support propofol or dexmedetomidine over benzodiazepines in most adult ICU patients when feasible, citing shorter time to extubation and better patient outcomes. Midazolam remains appropriate for specific ICU indications (e.g., refractory status epilepticus, procedural sedation in intubated patients, alcohol withdrawal in certain protocols).

Nayzilam (Midazolam Nasal Spray) — Epilepsy Rescue

For outpatient epilepsy patients on Nayzilam for seizure rescue, providers should:

Direct patients to UCB's patient support program (1-888-786-5879) and specialty pharmacies rather than general retail chains

Have a documented backup rescue prescription ready: Valtoco (diazepam nasal spray) for ages 12+ or ages 2+ depending on need, or Diastat (rectal diazepam) for patients who cannot use intranasal formulations

Educate patients and caregivers to keep at least a 30-day supply on hand and not wait until exhausted to refill

DEA and Controlled Substance Prescribing Considerations

Midazolam is a DEA Schedule IV controlled substance. During shortage conditions, prescribers should be aware that:

Schedule IV prescriptions have dispensing limitations: generally a maximum of 6 months' supply with a maximum of 5 refills, but rules vary by state

Pharmacies may limit their controlled substance inventory, so providing the specific NDC on the prescription can help pharmacies source the exact product

Partial fills and early refills for controlled substances have specific legal requirements; counsel patients accordingly

How to Help Your Patients Find Midazolam

When patients have trouble filling midazolam prescriptions, refer them to medfinder for Providers. medfinder calls pharmacies near the patient to identify which ones can fill their specific prescription, delivering results by text — reducing the burden on your office staff and improving patient safety for time-sensitive medications like seizure rescue therapy.

Monitoring Shortage Status

FDA Drug Shortage Database: dps.fda.gov/drugshortages

ASHP Drug Shortages Resource Center: ashp.org/drug-shortages

UCB Nayzilam field medical and sales contacts for specialty supply issues

For a step-by-step approach to helping patients locate midazolam, see our companion article: How to Help Your Patients Find Midazolam in Stock: A Provider's Guide.