Nitro-Bid Shortage: A Provider's Clinical Update for 2026

Nitroglycerin 2% topical ointment, formerly marketed as Nitro-Bid, has experienced ongoing supply constraints that directly affect patient care. This article provides prescribers and clinical staff with current shortage intelligence, evidence-based therapeutic alternatives, and practical strategies for managing affected patients.

Current Supply Landscape

The Nitro-Bid brand (Savage Laboratories) has been permanently discontinued. Generic Nitroglycerin 2% ointment remains available from a limited number of manufacturers, but production is inconsistent. Key factors driving the supply constraint include:

• Manufacturer consolidation: Only a small number of generic manufacturers produce Nitroglycerin ointment, creating vulnerability to single-point-of-failure disruptions.
• Low commercial priority: The ointment formulation represents a small share of the overall nitrate market compared to transdermal patches and oral formulations, reducing manufacturers' financial incentive to maintain robust production capacity.
• Raw material complexity: Nitroglycerin requires specialized handling and sourcing, and any disruption in the active pharmaceutical ingredient (API) supply chain cascades to finished product availability.
• Regulatory factors: FDA manufacturing standards and inspection requirements can create additional bottlenecks for facilities producing controlled-release topical formulations.

Clinical Implications

Patients currently maintained on Nitroglycerin ointment for chronic angina prophylaxis may present to your practice with difficulty obtaining refills. Several clinical considerations warrant attention:

• Abrupt discontinuation risk: Patients who have been on chronic nitrate therapy may experience rebound angina if therapy is discontinued abruptly. Published data suggest that nitrate-free intervals can precipitate increased anginal episodes, and complete withdrawal may carry risk for patients with significant coronary artery disease.
• Tolerance and dosing: Recall that all Nitroglycerin formulations require a daily nitrate-free interval (typically 10-12 hours) to preserve efficacy. When transitioning patients to alternative formulations, ensure the dosing regimen accounts for tolerance prevention.
• Patient anxiety: Medication access issues create significant distress for patients with cardiac conditions. Proactive communication and contingency planning can mitigate this burden.

Therapeutic Alternatives

When Nitroglycerin ointment is unavailable, the following evidence-based alternatives should be considered. The choice of agent depends on the patient's clinical profile, comorbidities, and medication tolerance.

Nitroglycerin Transdermal Patches (Nitro-Dur, Minitran)

The most pharmacologically similar alternative. Transdermal patches deliver Nitroglycerin through the skin in a controlled manner.

• Dosing: Available in 0.1 mg/hr to 0.8 mg/hr. Apply for 12-14 hours, remove for 10-12 hours. Start at 0.2-0.4 mg/hr and titrate.
• Conversion: No established direct conversion from ointment to patch. Base initial patch dose on clinical response and titrate accordingly.
• Availability: Generally better than ointment; multiple manufacturers produce generic patches.

Isosorbide Mononitrate (ISMN, Imdur)

A long-acting oral nitrate with well-established efficacy in chronic angina prophylaxis.

• Dosing: Extended-release: Start 30-60 mg once daily in the morning. May titrate to 120 mg/day. Immediate-release: 20 mg twice daily, doses 7 hours apart.
• Advantages: Oral dosing, excellent generic availability, low cost, once-daily extended-release option.
• Considerations: Headache is common (up to 38% incidence), particularly during initiation. Tolerance develops in the same manner as with topical Nitroglycerin.

Isosorbide Dinitrate (ISDN, Isordil)

Another oral nitrate option, though less commonly first-line due to more complex dosing.

• Dosing: 5-40 mg two to three times daily with an asymmetric dosing schedule to maintain a nitrate-free interval.
• Considerations: Useful for patients who require combination with Hydralazine (e.g., BiDil for heart failure with reduced ejection fraction in self-identified Black patients).

Non-Nitrate Alternatives

For patients who cannot tolerate nitrates or in whom nitrate therapy is contraindicated:

• Beta-blockers (Metoprolol, Atenolol): First-line for chronic stable angina; reduce myocardial oxygen demand.
• Calcium channel blockers (Amlodipine, Diltiazem): Particularly useful if beta-blockers are contraindicated.
• Ranolazine (Ranexa): Second-line agent; can be used as monotherapy or add-on therapy. Mechanism involves late sodium current inhibition.

Patient Management Strategies

1. Proactive prescribing: If supply is uncertain, consider writing prescriptions with "generic Nitroglycerin ointment 2%" to maximize pharmacy flexibility.
2. Pre-authorize alternatives: Document in the patient's chart an acceptable alternative medication and dose so that if Nitroglycerin ointment becomes unavailable, the patient's pharmacist can contact you for a quick switch rather than the patient going without medication.
3. Leverage pharmacy tools: Direct patients to MedFinder for providers to help locate pharmacies with current stock of Nitroglycerin ointment.
4. Compounding as backup: Compounding pharmacies can prepare Nitroglycerin ointment. Write prescriptions specifying compounding when commercial product is unavailable.
5. Bridge prescriptions: For patients at risk of running out, consider writing a short-term bridge prescription for a Nitroglycerin patch or oral ISMN while awaiting ointment availability.

Drug Interaction Reminders

When transitioning patients between nitrate formulations, reinforce critical drug interactions:

• PDE-5 inhibitors (Sildenafil, Tadalafil, Vardenafil): Absolutely contraindicated with all nitrate formulations. Severe, potentially fatal hypotension can result.
• Riociguat: Contraindicated with nitrates.
• Antihypertensives and vasodilators: Additive hypotensive effects. Monitor blood pressure during transitions.
• Alcohol: Potentiates hypotensive effects.

For detailed interaction information, see Nitro-Bid drug interactions: What to avoid.

Reporting and Advocacy

Providers can help address drug shortages by:

• Reporting unavailability to the FDA Drug Shortage Staff
• Notifying your institution's pharmacy and therapeutics (P&T) committee
• Communicating shortages to professional organizations (ACC, AHA)
• Documenting patient impact for potential manufacturer and FDA follow-up

Resources for Providers

• MedFinder Provider Portal — Help patients locate Nitro-Bid and other medications in stock
• FDA Drug Shortages Database
• How to help your patients find Nitro-Bid in stock: A provider's guide
• How to help patients save money on Nitro-Bid

The Bottom Line

The Nitro-Bid brand is discontinued and generic Nitroglycerin ointment supply remains unpredictable in 2026. Proactive patient management — including documented alternative regimens, early refill strategies, and use of tools like MedFinder — can minimize disruption to patient care. When transitioning patients, ensure appropriate dose conversion, maintain nitrate-free intervals, and reinforce critical drug interactions.