With the looming deadline of the temporary ceasefire between Iran and the U.S. approaching, focus is shifting back to the fallout of the conflict and how it directly affects pharmaceutical supplies.

The continued conflict in the Middle East, upstream ingredient dependencies, and the unresolved tariff landscape are converging on a pharmaceutical supply chain that is operating close to the edge.

A new vulnerability assessment from the U.S. Pharmacopeia (USP) highlights how the U.S. remains structurally exposed to drug shortages at every tier of the supply chain, from key starting materials sourced in politically volatile regions to finished-dose injectables competing for scarce airfreight capacity above a war zone.¹

The question is no longer whether disruption will occur, but whether the industry has enough visibility and lead time to respond before patients feel the impact.

What data was included in USP's vulnerable medicines list?

One of the key discoveries of the assessment noted that, of the 100 drugs identified as most vulnerable (50 acute and 50 chronic), 48% have at least one key starting material produced exclusively in a single country.¹ This finding means nearly half of the nation's most critically needed medicines depend on an upstream ingredient source that, if disrupted, would cascade simultaneously across every manufacturer downstream.

Three high-volume essential medicines were included in USP’s vulnerable supply list specifically because of this dynamic, including oseltamivir capsules, famotidine injection, and metoprolol tartrate injection. None were previously flagged or are currently in shortage, and appear stable at the finished-dose level, which makes their upstream exposure easy to overlook.

Over 25 of the 100 drugs on the updated list share the same profile, assessed as adequate at the finished-dose tier, structurally fragile when viewed from the key starting material (KSM) level up.¹

The composition of the list reinforces persistent structural patterns, with injectables accounting for 63% of flagged drugs, remaining consistent with their well-documented manufacturing complexity.

As of February 2026, 30 of the 100 drugs were included in active FDA shortage. This means the remaining 70 are on the list not because they are in crisis today, but because the architecture of their supply chains hold potential to make them candidates for one.

Which drugs are most at risk?

The following drugs are at the highest risk of suffering a supply shortage:

ICU & Critical Care

• Midazolam Injection
• Rocuronium Bromide Injection
• Dexmedetomidine Injection
• Etomidate Injection

IV Fluids & Electrolytes

• Dextrose Injection
• Sodium Chloride Injection
• Sterile Water for Injection
• Sodium Bicarbonate Injection

Pain & Opioid Analgesics

• Morphine Injection
• Hydromorphone Hydrochloride Injection

Cardiovascular

• Dopamine Hydrochloride Injection
• Dobutamine in Dextrose Injection
• Vasopressin Injection

Oncology

• Carboplatin Injection
• Doxorubicin Hydrochloride Injection

Neurology & Psychiatry

• Lorazepam Injection
• Diazepam Injection & Oral Solution
• Amphetamine Mixed Salts / Lisdexamfetamine

Antibiotics & Infection

• Vancomycin Injection
• Metronidazole Injection

Each drug is currently in an active FDA shortage and also appears on the WHO and/or FDA Essential Medicines List, highlighting the broad clinical consensus they are irreplaceable.¹ Most are injectables used in time-critical settings where a pharmacist cannot simply swap in an alternative without meaningful clinical tradeoffs.

IV fluids like normal saline, dextrose, and sterile water are the most systemically dangerous shortages on the list, as they underpin the delivery of dozens of other drugs. A shortage of IV fluids doesn't just affect one treatment, but it cascades across an entire hospital formulary simultaneously.¹

Risks with ICU sedatives and paralytics such as midazolam, rocuronium, and dexmedetomidine are particularly alarming as they are used in life-or-death moments such as intubation, mechanical ventilation, and emergency procedures where delays of even minutes can be catastrophic and substitutes.

Opioid analgesics are at heightened risk due to both morphine and hydromorphone being in shortage at the same time, eliminating the typical clinical fallback, which hits trauma, surgical, and palliative care patients hardest.

Meanwhile, the ADHD stimulant shortage, which is now entering its third year, reflects a structural problem with DEA manufacturing quotas that have shown little sign of resolution despite sustained demand.

Across all categories, the common thread is concentration risk, as manufacturers, domestic production, and supply chains never fully recovered from pandemic-era disruptions, allowing for a disruption such as the conflict in the Middle East to highlight the drugs most likely to enter shortage crisis.

How is the Iran War Disrupting Pharmaceutical Logistics?

Separate from USP’s most vulnerable medicines list, a document from USP emailed to Pharmaceutical Executive, identifies specific products with notable manufacturing exposure in the region.

In the document, USP notes that Jordan accounts for 48% of amoxicillin oral suspension production and 48% of etomidate API. Doxycycline hyclate capsules draw 24% of production from Jordan, and Flumazenil API is produced in both Israel and Jordan at a combined rate of 73%.

These figures represent a different category of risk; not hidden upstream fragility, but direct geographic exposure in an active conflict zone.

The conflict's most immediate operational impact is on air and ocean freight. Dan Bell, chief strategy officer for Marken UPS Healthcare Precision Logistics and a licensed U.S. customs broker with more than 26 years of experience in life science logistics, described the disruption in an exclusive Q&A with Pharmaceutical Executive.

"Due to the war, there are places in the region that can no longer be safely reached, especially by air," Bell said. "Airlines are now operating to go around a no-fly zone. Since the Strait of Hormuz is closed, the price of fuel will continue to skyrocket."

For pharmaceuticals, air freight is the preferred mode of transport. Shipments reach their destination faster and on an exact schedule, with ocean routing not often a viable substitute for time and temperature sensitive products.

The Red Sea corridor carries separate but related risk. It sits along the same trade routes that India uses to ship large volumes of active pharmaceutical ingredients and finished dosage forms to the U.S. and Europe. Even modest increases in transit time can trigger shortages for products already operating with thin inventory margins.

The Strait of Hormuz, while less directly implicated in pharmaceutical shipments, represents a critical route for global petroleum transport, and petroleum-derived inputs are essential to the production of key starting materials.

In his conversation with Pharmaceutical Executive, Bell noted that the downstream implications extend beyond freight costs.

"There are also the delays in clinical trials and what this will do to research, or lack thereof. Another consideration is supply shortages. Even for a lot of things most don't consider, like ancillary materials for clinical trials. When aluminum costs rise, other things are going to go up too, such as packaging. These are all going to go up. Companies will see an increase in costs across the board," said Bell.

Sources

1. 2025 Vulnerable Medicine List: Addressing Strategic Constraints to Strengthen the U.S. Medicine Supply Chain U.S. PharmacopeiaAccessed April 21, 2026 https://www.usp.org/sites/default/files/usp/document/public-policy/vulnerable-medicines-list-2025.pdf
2. World Health Organization. WHO Model Lists of Essential Medicines. 2025. Accessed April 21, 2026 https://www.who.int/groups/expert-committee-on-selection-and-use-of-essential-medicines/essential-medicines-lists