Provider Briefing: Nitroglycerin Supply Disruption in 2026

The Nitroglycerin supply shortage — particularly affecting sublingual tablets and injectable formulations — has persisted since 2023 and continues to impact patient care heading into 2026. This briefing provides prescribers with current status information, clinical implications, alternative prescribing strategies, and tools to help patients maintain access to this essential cardiovascular medication.

Shortage Timeline and Current Status

Nitroglycerin has experienced recurring supply disruptions across multiple formulations:

• 2023: FDA added Nitroglycerin sublingual tablets to the drug shortage list following manufacturing disruptions at Pfizer (Nitrostat), the dominant market supplier. Injectable Nitroglycerin also experienced supply constraints affecting hospital settings.
• 2024: Intermittent availability continued. Some regions reported normalized supply for sublingual tablets while others experienced persistent gaps. Generic sublingual tablet supply remained inconsistent due to few ANDA holders.
• 2025: Supply improved marginally but remained fragile. Hospital-based injectable shortages prompted institutional protocols for alternative IV vasodilators. Retail availability of sublingual tablets continued to vary by geography.
• 2026 (current): The shortage persists in an intermittent pattern. Sublingual tablets remain the most affected formulation. Transdermal patches and translingual sprays have generally maintained better availability. The FDA continues to monitor and work with manufacturers.

Prescribing Implications

The shortage creates several clinical challenges for providers:

Acute Angina Management

Sublingual Nitroglycerin (0.4 mg) remains first-line therapy for acute angina episodes. When sublingual tablets are unavailable, the translingual spray (Nitrolingual Pumpspray 0.4 mg/spray or Nitromist 0.4 mg/spray) provides an equivalent rapid-onset alternative. Consider proactively prescribing the spray for patients who report difficulty obtaining tablets.

Key prescribing note: The spray formulation uses a metered-dose delivery system. Counsel patients to spray onto or under the tongue (not inhale) and to prime the pump before first use. Dosing is equivalent — 1-2 sprays at onset of angina, repeated every 5 minutes for a maximum of 3 doses.

Angina Prophylaxis

For patients requiring long-acting nitrate prophylaxis, consider the following when Nitroglycerin patches are unavailable:

• Isosorbide Mononitrate (ISMN): Extended-release 30-120 mg once daily. Well-established efficacy, widely available generic, low cost ($10-$30/month). Requires asymmetric dosing schedule if using immediate-release formulation to prevent tolerance.
• Isosorbide Dinitrate (ISDN): 10-40 mg 2-3 times daily with nitrate-free interval. Available as oral and sublingual formulations. The sublingual form offers moderately rapid onset for patients who need both prophylaxis and semi-acute relief.

Tolerance and Nitrate-Free Intervals

When switching between Nitroglycerin formulations or to other nitrates, maintain appropriate nitrate-free intervals (typically 10-14 hours) to prevent tolerance. This applies to all organic nitrates regardless of formulation.

Current Availability Picture

Availability varies by formulation, region, and distribution channel:

Cost and Patient Access Considerations

The shortage has created cost pressures for patients:

• When generic sublingual tablets are unavailable, patients may face brand-name pricing ($30-$80 for 25 tablets vs. $15-$50 generic)
• Spray formulations cost significantly more ($60-$200) and may not be covered at the same tier
• Generic patches remain cost-effective ($20-$60/month) and represent a good value for prophylactic therapy

For patients experiencing financial barriers:

• Discount card programs (GoodRx, SingleCare, RxSaver) can reduce costs for both brand and generic formulations
• Patient assistance programs through Pfizer (RxPathways) and NeedyMeds may help uninsured patients
• Formulary considerations: Check whether the spray is covered under the patient's plan before prescribing as a tablet substitute

For a patient-facing guide on cost savings, direct patients to: How to save money on Nitroglycerin. For provider-specific guidance, see: How to help patients save money on Nitroglycerin: A provider's guide.

Tools and Resources for Providers

MedFinder for Providers

MedFinder for Providers allows clinicians and practice staff to check real-time Nitroglycerin availability at pharmacies in the patient's area before writing or sending a prescription. This reduces the cycle of patients bouncing between pharmacies with unfilled prescriptions.

Consider incorporating a MedFinder availability check into your workflow when prescribing any shortage-affected medication. For a detailed workflow guide, see: How to help your patients find Nitroglycerin in stock.

Additional Resources

• FDA Drug Shortage Database: accessdata.fda.gov/scripts/drugshortages — official shortage status and estimated resolution dates
• ASHP Drug Shortage Resource Center: Provides clinical alternatives and management guidance for healthcare professionals
• ACC/AHA Guidelines: Refer to current stable ischemic heart disease guidelines for evidence-based alternative anti-anginal strategies

Alternative Prescribing Strategies

When Nitroglycerin is unavailable, consider the following evidence-based alternatives depending on the clinical indication:

For Acute Angina Relief (Rescue)

1. Nitroglycerin translingual spray (first-line alternative — same drug, different delivery)
2. Sublingual Isosorbide Dinitrate 2.5-5 mg (somewhat slower onset; reasonable alternative)

For Angina Prophylaxis

1. Isosorbide Mononitrate ER 30-120 mg daily (widely available, first-line substitution)
2. Isosorbide Dinitrate 10-40 mg BID-TID with nitrate-free interval
3. Ranolazine (Ranexa) 500-1000 mg BID (non-nitrate; for patients intolerant or refractory to nitrates)
4. Calcium channel blockers (Amlodipine, Diltiazem) — particularly useful in vasospastic angina
5. Beta-blockers — first-line for angina prophylaxis; optimize dosing before adding nitrates

For patient-facing information on alternatives, direct patients to: Alternatives to Nitroglycerin if you can't fill your prescription.

Looking Ahead

The structural vulnerabilities in the Nitroglycerin supply chain — concentrated manufacturing, specialized production requirements, limited API suppliers — are unlikely to resolve quickly. Providers should:

• Proactively discuss supply concerns with patients during routine cardiology and primary care visits
• Consider prescribing Nitroglycerin spray alongside or instead of sublingual tablets to give patients an available alternative
• Ensure patients understand the difference between rescue and prophylactic anti-anginal therapy
• Stay current on FDA shortage updates and have alternative prescribing protocols ready

Final Thoughts

The Nitroglycerin shortage requires proactive management at the provider level. By diversifying formulation prescribing, maintaining familiarity with alternative anti-anginal agents, and leveraging availability tools like MedFinder for Providers, clinicians can help ensure their patients maintain access to effective angina therapy even during supply disruptions.

For patient education resources, share our articles on the shortage update for patients, Nitroglycerin uses and dosage, and Nitroglycerin side effects.