About

Shailina A Keshwani, Ph.D., M.S., is a Research Assistant Professor in the Department of Pharmaceutical Outcomes and Policy at the University of Florida. She works under the supervision of Dr. Steven Smith. Dr. Keshwani earned her Bachelor of Science in Pharmacy from Mumbai University in 2012, completed a Master of Science in Pharmaceutical Sciences at the University of Florida in 2021, and obtained her Ph.D. in Pharmaceutical Sciences from the same department in Spring 2025. Her research focuses on health policy and the intersection of pain management and cardiovascular diseases, with particular emphasis on the use of analgesics in patients with cardiovascular comorbidities that may contraindicate such treatments. Her work aims to enhance the understanding of analgesic safety and effectiveness in geriatric patients, ultimately contributing to safer, evidence-based approaches to pain management.

Research topics

• Medicine
• Psychiatry
• Family medicine
• Political Science
• Internal medicine
• Emergency medicine
• Pathology
• Demography
• Nursing

Selected publications

• Association Between Different Analgesic Use and Hypertension Among Medicare Beneficiaries With Osteoarthritis

  Journal of the American Geriatrics Society · 2026-03-15

  article1st authorCorresponding

  BACKGROUND: In older adults with osteoarthritis (OA) and hypertension (HTN), analgesic use may elevate blood pressure and cardiovascular risk. Whether comorbid HTN influences initial analgesic choice remains unclear; we examined initial analgesic use in Medicare beneficiaries with incident OA, comparing those with and without HTN. METHODS: We conducted a retrospective cohort study using 2011-2022 nationally representative Medicare beneficiaries (≥ 65 years) with incident OA who initiated an analgesic within 30 days of diagnosis and had continuous enrollment for ≥ 365 days prior through ≥ 30 days post-index. Patients with baseline HTN were classified as OA + HTN; others as OA-only. We assessed overall analgesic trends using the Cochran-Armitage test and evaluated differences by HTN status using logistic regression with year as an interaction term. For stratified analyses by joint type, we applied weighted logistic regression. RESULTS: Among 179,033 beneficiaries (mean age 75 ± 7.3 years; 62.7% women; 80.7% White), 57.1% had baseline HTN. Overall, the most commonly initiated analgesic classes were intra-articular injections (30.3%), and oral NSAIDs only (28.2%). Notable changes from 2012 to 2022 were increase in topical NSAIDs use (3.1%-5.7%) and decrease in opioid combination use (25.4%-13.9%), with no significant trend differences by HTN status. In joint-specific analyses, OA + HTN versus OA-only showed no differences in odds of initiating oral opioids (OR: 0.97, 95% CI: 0.92-1.03), intra-articular injections (OR: 1.01, 95% CI: 0.96-1.07) or topical NSAIDs (OR: 0.88, 95% CI: 0.78-1.01) versus oral NSAIDs. CONCLUSION: Baseline HTN did not influence the choice of initial analgesic in incident OA patients. Safer, evidence-based alternatives are needed for older adults with comorbid HTN.

  PublisherDOI

• High-Throughput Screening for Prescribing Cascades Among Real-World Angiotensin-II Receptor Blockers (ARBs) Initiators

  medRxiv · 2025-03-11 · 2 citations

  preprintOpen access

  Objective: Angiotensin-II Receptor Blockers (ARBs) are commonly prescribed; however, their adverse events may prompt new drug prescription(s), known as prescribing cascades. We aimed to identify potential ARB-induced prescribing cascades using high-throughput sequence symmetry analysis. Methods: Using claims data from a national sample of Medicare beneficiaries (2011-2020), we identified new ARB users aged ≥66 years with continuous enrollment ≥360 days before and ≥180 days after ARB initiation. We screened for initiation of 446 other (non-antihypertensive) 'marker' drug classes within ±90 days of ARB initiation, generating sequence ratios (SRs) reflecting proportions of ARB users starting the marker class after versus before ARB initiation. Adjusted SRs (aSRs) accounted for prescribing trends over time, and for significant aSRs, we calculated the naturalistic number needed to harm (NNTH); significant signals were reviewed by clinical experts for plausibility. Results: We identified 320,663 ARB initiators (mean ± SD age 76.0 ± 7.2 years; 62.5% female; 91.5% with hypertension). Of the 446 marker classes evaluated, 17 signals were significant, and three (18%) were classified as potential prescribing cascades after clinical review. The strongest signals ranked by the lowest NNTH included benzodiazepine derivatives (NNTH 2130, 95% CI 1437-4525), adrenergics in combination with anticholinergics, including triple combinations with corticosteroids (NNTH 2656, 95% CI 1585-10074), and other antianemic preparations (NNTH 9416, 95% CI 6606-23784). The strongest signals ranked by highest aSR included other antianemic preparations (aSR 1.7, 95% CI 1.19-2.41), benzodiazepine derivatives (aSR 1.18, 95% CI 1.08-1.3), and adrenergics in combination with anticholinergics, including triple combinations with corticosteroids (aSR 1.12, 95% CI 1.03-1.22). Conclusion: The identified prescribing cascade signals reflected known and possibly under-recognized ARB adverse events in this Medicare cohort. These hypothesis-generating findings require further investigation to determine the extent and impact of these prescribing cascades on patient outcomes.

  PublisherOA PDFDOI

• High‐Throughput Screening for Prescribing Cascades Among Real‐World Angiotensin‐Converting Enzyme Inhibitor Initiators

  Pharmacoepidemiology and Drug Safety · 2025-03-01 · 3 citations

  articleOpen access

  ABSTRACT Purpose Angiotensin‐converting enzyme inhibitors (ACEIs) are commonly prescribed, but their adverse effects may prompt new drug prescription(s), known as prescribing cascades (PCs). We aimed to identify potential ACEI‐induced PCs using high‐throughput sequence symmetry analysis. Methods Using claims data from a national sample of Medicare beneficiaries (2011–2020), we identified new ACEI users aged ≥ 66 years with continuous enrollment ≥ 360 days before and ≥ 180 days after ACEI initiation. We screened for initiation of 446 other (non‐antihypertensive) “marker” drug classes within ±90 days of ACEI initiation, generating sequence ratios (SRs) reflecting proportions of ACEI users starting the marker class after versus before ACEI initiation. Adjusted SRs (aSRs) accounted for prescribing trends over time. For significant aSRs, we calculated the naturalistic number needed to harm (NNTH), and significant signals underwent clinical review for plausibility. Results We identified 308 579 ACEI initiators (mean age 76.1 ± 7.5 years; 59.6% female; 88.6% with hypertension). Of 446 marker classes evaluated, 81 signals were significant, and 42 (52%) classified as potential PCs after clinical review. The strongest signals ranked by lowest NNTH included corticosteroids (NNTH 313; 95% CI, 262–392) and serotonin type 3 (5‐HT 3 ) antagonists (NNTH 496; 95% CI, 392–689); the strongest signals ranked by highest aSR included sympathomimetics (aSR, 1.97; 95% CI, 1.10–3.53) and other antianemic preparations (aSR, 1.87; 95% CI, 1.31–2.67). Conclusion Identified prescribing cascade signals were indicative of known and possibly underrecognized ACEI adverse events in this Medicare cohort. The findings are hypothesis‐generating and require further investigation to determine the extent and impact of the identified PCs on health outcomes.

  PublisherOA PDFDOI

• High‐Throughput Screening for Prescribing Cascades Among Real‐World Angiotensin‐ <scp>II</scp> Receptor Blockers ( <scp>ARBs</scp> ) Initiators

  Pharmacotherapy The Journal of Human Pharmacology and Drug Therapy · 2025-10-21 · 1 citations

  article

  OBJECTIVE: Angiotensin-II Receptor Blockers (ARBs) are commonly prescribed; however, their adverse events may prompt new drug prescriptions, known as prescribing cascade (PC). We aimed to identify potential ARB-induced PCs using high-throughput sequence symmetry analysis. METHODS: Using claims data from a national sample of Medicare beneficiaries (2011-2020), we identified new ARB users aged ≥ 66 years with continuous enrollment ≥ 360 days before and ≥ 180 days after ARB initiation. We screened for initiation of 446 other (non-antihypertensive) "marker" drug classes within ±90 days of ARB initiation. Sequence ratios (SRs) with 95% confidence intervals (CIs) were calculated as the ratio of the number of ARB users initiating the marker class after versus before ARB initiation. Adjusted SRs (aSRs) accounted for prescribing trends over time, and for significant aSRs, we calculated the naturalistic number needed to harm (NNTH); significant signals were reviewed by clinical experts for plausibility. RESULTS: We identified 320,663 ARB initiators, age (mean ± standard deviation) 76.0 ± 7.2 years; 62.5% female; and 91.5% with hypertension. Of the 446 marker classes evaluated, 17 signals were significant, and three (18%) were classified as potential PCs after clinical review. The strongest signals ranked by the lowest NNTH included benzodiazepine derivatives (NNTH 2130, 95% CI 1437-4525), adrenergics in combination with anticholinergics, including triple combinations with corticosteroids (NNTH 2656, 95% CI 1585-10,074), and other antianemic preparations (NNTH 9416, 95% CI 6606-23,784). The strongest signals ranked by highest aSR included other antianemic preparations (aSR 1.7, 95% CI 1.19-2.41), benzodiazepine derivatives (aSR 1.18, 95% CI 1.08-1.3), and adrenergics in combination with anticholinergics, including triple combinations with corticosteroids (aSR 1.12, 95% CI 1.03-1.22). CONCLUSION: The identified PC signals reflected known and possibly under-recognized ARB adverse events in this Medicare cohort. These hypothesis-generating findings require further investigation to determine the extent and impact of these PCs on patient outcomes.

  PublisherDOI

• Unsupervised learning using EHR and census data to identify distinct subphenotypes of newly diagnosed hypertension patients

  PLoS ONE · 2025-07-09 · 2 citations

  articleOpen access

  BACKGROUND: Hypertension (HTN) is a complex condition with significant heterogeneity in presentation and treatment response. Identifying distinct subphenotypes of HTN may improve our understanding of its underlying mechanisms and guide more precise treatment or public health initiatives. METHODS: Using EHR and Medicaid claims data from the OneFlorida+ research consortium (2012-2021), we identified a cohort of adult Floridians with newly diagnosed HTN (first diagnosis following two outpatient blood pressures ≥140/90 mmHg & no prior anti-HTN treatment). We extracted demographic and clinical data from the diagnosis visit and ≤1 year prior. We used hierarchical clustering (unsupervised machine learning) to identify distinct subphenotypes within the OneFlorida+ HTN population. RESULTS: A total of 40,686 patients were included (mean ± SD age, 60.9 ± 17.5 y; 55% women). Five subphenotypes (S1-5) were identified. S1 was characterized by older age, higher Body Mass Index (BMI), and prevalent type 2 diabetes. S2 included over 50% of Black patients who were primarily women, younger, with higher BMI, but living in communities with higher levels of socioeconomic vulnerabilities. S3 contained a higher percentage of Hispanic patients with comparatively lower BMI. S4 is characterized by higher age and co-morbidities. S5 had 94% of patients with chronic kidney disease. Distinctions in social determinants of health factors were also observed. CONCLUSIONS: Unsupervised learning identified 5 HTN subphenotypes varying in demographic, socioeconomic, and risk profiles. Further investigation into the biological mechanisms of these subphenotypes and the relationships to social factors may enhance our ability to deliver targeted interventions that consider social policy implications in addition to the traditional behavioral and physiological interventions.

  PublisherDOI

• Disparities in Initial Antihypertensive Intensity by Sex, Race and Ethnicity in Newly Treated Patients With Hypertension

  American Journal of Hypertension · 2025-04-22 · 1 citations

  articleOpen access1st authorCorresponding

  BACKGROUND: Sex, race, and ethnicity disparities in hypertension (HTN) treatment intensity have been previously described. It remains unclear if these disparities occur at treatment onset and whether they can be explained by differences in clinical factors. METHODS: We conducted a retrospective cross-sectional study of adults with newly treated HTN using linked EHR + claims data from OneFlorida + Consortium. We included Florida Medicaid & Medicare-recipients diagnosed with HTN and prescribed ≥ 1 first-line antihypertensive during 2013-2020. We used generalized linear models to estimate differences in total therapeutic intensity score (TTIS)-a patient's total daily dose (TDD) divided by recommended maximum TDD for a drug, summed across entire regimen-by sex, race, and ethnicity. We then modeled the same, controlling for demographics, blood pressure, and relevant comorbidities. RESULTS: In total 4,094 patients (mean age 58 ± 16; female 57.6%; White 56.7%) were included. We observed variations in the initiation of antihypertensive classes by sex, race and ethnicity. In univariate analyses, men averaged 7.6% (95% CI: 3.9%-11.3%) greater TTIS versus women and Black individuals averaged 10.5% (95% CI: 6.6%-14.3%) greater TTIS versus White individuals, whereas no disparities were observed by ethnicity. After adjusting for clinical factors, these disparities persisted: men had 7.6% (95% CI: 3.9%-11.4%) greater TTIS versus women, and Black individuals had 17.9% (95% CI: 13.8%-21.9%) greater TTIS versus White individuals. CONCLUSIONS: We observed disparities in treatment intensity by sex and race that were not explained by differences in clinical factors. There was sex-based variation in practice patterns, and Black individuals received more intensive initial antihypertensive therapy than White individuals.

  PublisherOA PDFDOI

• A Mapping Literature Review of Medical Cannabis Clinical Outcomes and Quality of Evidence in Approved Conditions in the USA from 2016 to 2019

  UNC Libraries · 2024-01-09

  articleOpen access

  In 2017, a National Academies of Sciences, Engineering, and Medicine (NASEM) report comprehensively evaluated the body of evidence regarding cannabis health effects through the year 2016. The objectives of this study are to identify and map the most recently (2016-2019) published literature across approved conditions for medical cannabis and to evaluate the quality of identified recent systematic reviews, published following the NASEM report. Following the literature search from 5 databases and consultation with experts, 11 conditions were identified for evidence compilation and evaluation: amyotrophic lateral sclerosis, autism, cancer, chronic noncancer pain, Crohn's disease, epilepsy, glaucoma, human immunodeficiency virus/AIDS, multiple sclerosis (MS), Parkinson's disease, and posttraumatic stress disorder. A total of 198 studies were included after screening for condition-specific relevance and after imposing the following exclusion criteria: preclinical focus, non-English language, abstracts only, editorials/commentary, case studies/series, and non-U.S. study setting. Data extracted from studies included: study design type, outcome definition, intervention definition, sample size, study setting, and reported effect size. Few completed randomized controlled trials (RCTs) were identified. Studies classified as systematic reviews were graded using the Assessing the Methodological Quality of Systematic Reviews-2 tool to evaluate the quality of evidence. Few high-quality systematic reviews were available for most conditions, with the exceptions of MS (9 of 9 graded moderate/high quality; evidence for 2/9 indicating cannabis improved outcomes; evidence for 7/9 indicating cannabis inconclusive), epilepsy (3 of 4 graded moderate/high quality; 3 indicating cannabis improved outcomes; 1 indicating cannabis inconclusive), and chronic noncancer pain (12 of 13 graded moderate/high quality; evidence for 7/13 indicating cannabis improved outcomes; evidence from 6/7 indicating cannabis inconclusive). Among RCTs, we identified few studies of substantial rigor and quality to contribute to the evidence base. However, there are some conditions for which significant evidence suggests that select dosage forms and routes of administration likely have favorable risk-benefit ratios (i.e., epilepsy and chronic noncancer pain). The body of evidence for medical cannabis requires more rigorous evaluation before consideration as a treatment option for many conditions, and evidence necessary to inform policy and treatment guidelines is currently insufficient for many conditions.

  PublisherDOI

• Abstract 4142268: Calcium channel blocker-induced prescribing cascades: Signal detection using high-throughput sequence symmetry analysis

  Circulation · 2024-11-12

  article

  Background: Dihydropyridine calcium channel blockers (DHCCBs) are effective first-line therapy for hypertension but can cause adverse effects (AEs) leading to the prescription of a new drug, i.e., a ‘prescribing cascade.’ Aim: To identify potential DHCCB-induced prescribing cascades using high throughput sequence symmetry analysis (HTSSA). Methods: Using claims from 5% (2011-15) and 15% (2016-20) samples of Medicare fee-for-service beneficiaries, we identified new DHCCB users aged &gt; 66 y with continuous enrollment &gt; 360 days pre- and &gt; 180 days post-CCB initiation. We screened for the initiation of 446 other ‘marker’ drug classes (based on WHO Anatomical Therapeutic Classification level 4 codes) within + 90 days of DHCCB initiation. Adjusted sequence ratios (aSRs), representing proportions of DHCCB initiators starting the marker class after vs. those starting before DHCCB were calculated, with 95% CIs &gt;1 considered significant; for significant signals, the number needed to harm (NNTH) was also calculated. Independent clinical reviewers classified signals as potential prescribing cascades or not based on biological plausibility. Results: We identified 388,862 DHCCB initiators (mean + SD age 77 + 7.5 years; 62% female and 92% with hypertension). Of the 446 marker classes assessed, we identified 82 signals that warranted further exploration (aSR &gt; 1). After clinical review, 29 (35.36%) signals were classified as potential prescribing cascades (Figure 1). The top 3 potential prescribing cascades ranked by aSR were other systemic hemostatics (aSR 2.99 [1.10-8.16]), other nasal preparations (aSR 1.99 [1.47-2.70]), and drugs used in erectile dysfunction (aSR 1.85 [1.27-2.70]). Other clinically relevant signals included electrolyte solutions (NNTH 216, aSR 1.35), osmotically acting laxatives (NNTH 710, aSR 1.13), and sulfonamides (NNTH 104, aSR 1.50). Conclusion: HTSSA is a novel approach to identify DHCCB-induced potential prescribing cascades. Using this method, we identified known and underrecognized AEs of CCBs in this nationally-representative Medicare cohort. More research is needed to evaluate clinical outcomes attributed to these prescribing cascades.

  PublisherDOI

• Trends in Use of Prescription Nonsteroidal Anti-inflammatory Medications before vs after Implementation of a Florida Law Restricting Opioid Prescribing for Acute Pain

  UNC Libraries · 2024-01-09

  articleOpen accessSenior author

  Importance: Previous research has shown an immediate reduction in new opioid users and use after implementation of the opioid supply restriction laws. Assessment of the association between opioid restrictions and alternative treatment options, such as nonsteroidal anti-inflammatory drugs (NSAIDs), is needed to evaluate potential unintended consequences for patients requiring analgesia. Objective: To evaluate the association between an opioid restriction law in Florida and use of prescription NSAIDs. Design, Setting, and Participants: This quality improvement study used interrupted time series analyses accounting for autocorrelation to estimate immediate and trend changes in the prescribing and use of prescription NSAIDs in Florida before and after implementation of a state law limiting opioid prescriptions to a 3-day supply. Participants were enrollees in a single private health plan of a large university and health system employer in Florida from January 2015 to June 2019. Exposures: Prescriptions for NSAIDs, ascertained from pharmacy claims data. Main Outcomes and Measures: The following outcomes were calculated monthly per 1000 plan enrollees: (1) number of NSAID users; (2) mean days' supply of NSAIDs per prescription; and (3) mean number of NSAID prescriptions. Individuals were classified as NSAID users if they had at least 1 NSAID prescription in a given month. Analysis was stratified by route of NSAID administration (oral or nonoral). Results: Among 46783 NSAID users with 79089 NSAID prescriptions during the study period, the median age was 47 years (interquartile range, 35-57 years). After implementation of the opioid restriction law, the number of NSAID users immediately increased, but the difference was not significant (change, 0.82 per 1000 patients; 95% CI, -0.67 to 2.30 per 1000 patients). No significant change in the days' supply of oral NSAID users occurred (change, 0.21 days per prescription; 95% CI, -1.66 to 2.08 days per prescription). Before implementation of the law, there was a nonsignificant decreasing trend in NSAID prescriptions (rate of change, -0.03 per month per 1000 enrollees; 95% CI, -0.13 to 0.07 per month per 1000 enrollees; after implementation, there was a nonsignificant increase in the number of oral and nonoral NSAID prescriptions (change, 1.49 per 1000 enrollees; 95% CI, -3.38 to 6.37 per 1000 enrollees). Conclusions and Relevance: In this quality improvement study, prescribing and use of prescription NSAIDs did not increase after implementation of a law restricting opioid analgesic prescriptions in Florida. These findings suggest possible greater use of over-the-counter NSAIDs after implementation of the law, but further research is needed to evaluate changes in the use of nonopioid analgesics and alternative pain therapies.

  PublisherDOI

• Initial Antihypertensive Prescribing in Relation to Blood Pressure Among Florida Medicaid and Medicare Recipients in the OneFlorida+ Research Consortium

  Hypertension · 2024-01-17 · 1 citations

  articleOpen access
  PublisherOA PDFDOI

Frequent coauthors

• Earl J. Morris

  University of Florida

  22 shared

• Steven M. Smith

  University of Florida

  21 shared

• Almut G. Winterstein

  Center for Drug Evaluation and Research

  19 shared

• Amie Goodin

  17 shared

• Carl J. Pepine

  University of Florida

  15 shared

• Scott Martin Vouri

  Center for Drug Evaluation and Research

  14 shared

• Juan M. Hincapie‐Castillo

  University of North Carolina at Chapel Hill

  13 shared

• Kayla Smith

  University of Florida

  12 shared

Labs

• Department of Pharmaceutical Outcomes & Policy, College of Pharmacy, University of FloridaPI

Education

• PhD, Pharmaceutical Outcomes and Policy

  University of Florida

  2024

• MS, Pharmaceutical Outcomes and Policy

  University of Florida

  2021