Comprehensive medication guide to Pyridostigmine including estimated pricing, availability information, side effects, and how to find it in stock at your local pharmacy.
Estimated Insurance Pricing
$0–$30 copay for generic Pyridostigmine IR on most commercial plans (Tier 1–2); higher copays for ER formulation or brand-name Mestinon Timespan, which may require prior authorization on many plans.
Estimated Cash Pricing
$25–$35 retail for generic Pyridostigmine IR 60 mg (90 tablets) with GoodRx or SingleCare; $80–$150 for generic ER 180 mg when available; $490–$750 at full retail for the ER formulation. Brand-name Mestinon Timespan exceeds $800.
Medfinder Findability Score
45/100
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Pyridostigmine bromide is a cholinesterase inhibitor medication used primarily to treat myasthenia gravis (MG), a chronic autoimmune disorder that causes muscle weakness and fatigue. It is sold under the brand names Mestinon (immediate-release and extended-release tablets, oral solution) and Regonol (injectable form). Pyridostigmine has been in clinical use since 1955 and is on the World Health Organization's List of Essential Medicines.
The medication is available in three oral forms: 60 mg immediate-release (IR) tablets, 180 mg extended-release (ER) tablets (Mestinon Timespan), and 60 mg/5 mL oral solution (syrup). Generic versions of both the IR and ER formulations are widely manufactured, making Pyridostigmine accessible for most patients — though the generic ER formulation has faced significant supply disruptions since 2024.
In addition to myasthenia gravis, Pyridostigmine is FDA-approved to reverse nondepolarizing neuromuscular blockade after surgery and for military use as pre-exposure prophylaxis against the nerve agent Soman. It is also used off-label for postural orthostatic tachycardia syndrome (POTS) and neurogenic bladder. Pyridostigmine is not a DEA-scheduled controlled substance.
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Pyridostigmine works by blocking acetylcholinesterase, the enzyme responsible for breaking down acetylcholine at the neuromuscular junction. Acetylcholine is the chemical messenger that carries signals from nerve cells to muscle fibers, triggering contraction. In myasthenia gravis, the immune system attacks acetylcholine receptors on muscle cells, reducing the number available to receive these signals.
By inhibiting acetylcholinesterase, Pyridostigmine allows more acetylcholine to accumulate in the neuromuscular junction. With higher concentrations of acetylcholine, the available receptors are stimulated more effectively, improving nerve-to-muscle signal strength and enhancing muscle function. The effect begins within 15–30 minutes of an oral dose, lasting 3–6 hours for the immediate-release formulation and approximately 2.5 times longer for the extended-release tablets.
Importantly, Pyridostigmine does not cross the blood-brain barrier, so it acts only in the peripheral nervous system. It is a symptomatic treatment — it compensates for lost receptor function but does not address the underlying autoimmune cause of myasthenia gravis. Disease-modifying therapy (corticosteroids, immunosuppressants, or biologics) is typically required for long-term disease management.
60 mg — Immediate-release tablet
Most widely available and affordable formulation. Taken every 3–6 hours while awake.
180 mg — Extended-release tablet (Timespan)
Slower, more uniform drug release. Taken once or twice daily (at least 6 hours apart). Currently in limited supply for generic version.
60 mg/5 mL — Oral solution (syrup)
Raspberry-flavored liquid. Useful for swallowing difficulties or patients needing precise dose adjustment. May require special ordering.
Availability of Pyridostigmine depends heavily on the formulation. The generic 180 mg extended-release (ER) tablets have been in significant short supply since mid-2024, with generic manufacturers Alvogen and Rising Pharmaceuticals on back order with no confirmed return dates as of early 2026. Brand-name Mestinon Timespan is more consistently available but carries a list price exceeding $800 for a 30-day supply.
The immediate-release (IR) 60 mg generic tablets are generally available at most pharmacies. The oral solution (syrup) is available but may require special ordering at some retail locations. The FDA has not formally listed Pyridostigmine on its Drug Shortage Database as of early 2026, despite widespread patient-reported difficulties. As a result, there is no coordinated federal response.
For patients struggling to locate Pyridostigmine ER in stock, medfinder contacts pharmacies in your area to find which ones have your specific formulation and strength, texting results directly to you. Independent pharmacies (which use different wholesale distributors) and mail-order pharmacies like Amazon Pharmacy or Express Scripts may have stock when local chain pharmacies don't.
Pyridostigmine is not a DEA-scheduled controlled substance, so there are no special federal restrictions on who may prescribe it. Any licensed healthcare provider with prescribing authority in their state may prescribe Pyridostigmine, including telehealth providers. New diagnoses of myasthenia gravis, however, typically require in-person neurological evaluation and diagnostic workup before initiating treatment.
Providers who commonly prescribe Pyridostigmine include:
Neurologists (primary specialists for myasthenia gravis)
Neuromuscular specialists (subspecialty neurology for complex MG cases)
Primary care physicians (PCPs) (for established patients with confirmed diagnoses)
Cardiologists (for POTS patients)
Nurse practitioners (NPs) and physician assistants (PAs) (in most states, in collaboration with or under supervision of a physician)
Pediatric neurologists (for juvenile myasthenia gravis)
Telehealth is an option for established MG patients needing prescription refills or monitoring, particularly in rural areas. Initial MG diagnosis and crisis management require in-person evaluation. Platforms such as Teladoc, MDLive, and health system telehealth portals typically can accommodate Pyridostigmine refills for stable patients.
No. Pyridostigmine bromide is not a DEA-scheduled controlled substance. It has no abuse or dependence potential and is not subject to the special prescription requirements, refill restrictions, or quantity limits that apply to controlled substances such as opioids, stimulants, or benzodiazepines.
Because it is not controlled, any licensed prescriber in the United States — including primary care physicians, neurologists, nurse practitioners, physician assistants, and telehealth providers — can prescribe Pyridostigmine without DEA registration restrictions. Prescriptions can be transmitted electronically, by phone, or in writing, and there are no limits on refills based on controlled substance classification.
Side effects are primarily dose-related and fall into two categories: muscarinic (smooth muscle and gland effects) and nicotinic (neuromuscular junction effects).
Muscarinic side effects:
Nausea, vomiting, diarrhea, abdominal cramps
Increased salivation and tearing
Increased sweating (diaphoresis)
Increased bronchial secretions, miosis (pupil constriction), frequent urination
Nicotinic side effects:
Muscle cramps, fasciculations (muscle twitching)
Paradoxical weakness (at high doses — sign of overdose)
Serious side effects requiring emergency care:
Cholinergic crisis (overdose): severe progressive muscle weakness, excessive secretions, bradycardia, pinpoint pupils, profuse sweating — call 911
Allergic reactions: hives, difficulty breathing, facial or throat swelling
Severe bronchospasm (especially in asthma patients)
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Neostigmine (Prostigmin)
Closest pharmacological alternative to Pyridostigmine; same mechanism but shorter duration and more GI side effects. Mainly used IV/IM in hospital settings. Rarely used chronically for MG in the U.S.
Prednisone
Corticosteroid used as first-line immunosuppressive therapy for MG when cholinesterase inhibitors alone are insufficient. Reduces antibody production. Effective in 66–85% of patients. Requires careful monitoring.
Azathioprine (Imuran)
Immunosuppressant used as a steroid-sparing agent for long-term MG management. Takes 6–12 months to show full effect. Often combined with prednisone to allow steroid taper.
Efgartigimod alfa (Vyvgart)
FcRn inhibitor approved for anti-AChR antibody-positive generalized MG in adults. Reduces harmful antibody levels. Administered as IV infusion every 1–2 weeks. An option for moderate-to-severe or refractory disease.
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Corticosteroids (prednisone, methylprednisolone)
majorConcomitant use may produce severe weakness in MG patients. Withdraw anticholinesterase agents at least 24 hours before initiating corticosteroids when possible.
Anticholinergic drugs (atropine, tricyclic antidepressants, antihistamines, bladder medications)
moderateAntagonize Pyridostigmine's cholinergic effects, potentially reducing its therapeutic benefit and worsening muscle weakness.
Other cholinesterase inhibitors (donepezil, rivastigmine, galantamine)
moderateAdditive cholinergic effects increase risk of cholinergic toxicity. Use with caution if prescribed for a co-occurring condition like Alzheimer's disease.
Quinidine and procainamide
moderateAntiarrhythmic drugs that can antagonize Pyridostigmine at the neuromuscular junction and worsen MG symptoms.
Beta-blockers (metoprolol, atenolol, propranolol)
minorMay exacerbate bradycardia when combined with Pyridostigmine's cholinergic cardiac effects. Requires monitoring.
Amifampridine (Firdapse)
moderateBoth increase cholinergic transmission; may cause additive effects. Monitor closely when used together.
Aminoglycoside and fluoroquinolone antibiotics
moderateMay worsen neuromuscular blockade and exacerbate MG symptoms. This is an interaction with the underlying disease rather than with Pyridostigmine specifically.
Pyridostigmine has been a cornerstone of myasthenia gravis treatment for over 70 years and remains the most commonly used first-line symptomatic therapy for the condition. For most patients with MG, Pyridostigmine provides meaningful improvement in muscle strength and quality of life, allowing them to perform daily activities with greater confidence and stability.
The supply situation for the 180 mg ER formulation remains challenging in 2026, requiring patients to be proactive about filling their prescriptions early and exploring multiple pharmacy options. The immediate-release 60 mg tablets are generally more available and significantly more affordable. When the ER formulation is unavailable, switching to the IR formulation under your neurologist's guidance is the most practical bridging strategy.
If you or your patients are having difficulty locating Pyridostigmine in stock, medfinder is designed specifically to address this challenge — contacting pharmacies in your area to find which ones have your specific formulation, strength, and quantity available, and texting you the results.
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Our medication guides are researched and written to help patients make informed decisions. All content is reviewed for accuracy and updated regularly. Learn more about our standards
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Medfinder is actively checking pharmacy inventory for Pyridostigmine. We don't publish a number until we have enough verified pharmacy checks to be accurate — start a search and our team confirms current availability near you, usually within 24 hours.
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