FORA ADVANCED GD40 and FORA ADVANCED GD40 pro Blood Glucose and ß-Ketone Monitoring Systems

{0} 1 # 510(k) SUBSTANTIAL EQUIVALENCE DETERMINATION DECISION MEMORANDUM ASSAY AND INSTRUMENT COMBINATION TEMPLATE A. 510(k) Number: K161738 B. Purpose for Submission: New Submission C. Measurand: Glucose in capillary whole blood glucose from fingertip, venous and neonatal β-Ketone in capillary whole blood from fingertip, and venous D. Type of Test: Quantitative Amperometric assay (Glucose dehydrogenase (FAD)) and Quantitative Amperometric β-Ketone (beta-hydroxybutyrate) E. Applicant: TaiDoc Technology Corporation F. Proprietary and Established Names: FORA ADVANCED GD-40 Blood Glucose and β-Ketone Monitoring System FORA ADVANCED GD-40 pro Blood Glucose and β-Ketone Monitoring System G. Regulatory Information: 1. Regulation section: 862.1345, Glucose Test System 862.1435, Ketones (nonquantitative) test system 862.1660, Quality control material (assayed and unassayed) {1} 2. Classification: Class II Class I (reserved) 3. Product code: NBW - System, Test, Blood Glucose, Over-the-Counter LFR - Glucose Dehydrogenase, Glucose JIN – Nitroprusside, ketones (urinary, non-quant.) JJX - Single (specified) analyte controls (assayed and unassayed) 4. Panel: (75) Chemistry H. Intended Use: 1. Intended use(s): See indications for use below. 2. Indication(s) for use: FORA ADVANCED GD40 Blood Glucose and β-Ketone Monitoring System is intended for the quantitative measurement of glucose in fresh capillary whole blood from the finger, and for the quantitative measurement of β-ketone (beta-hydroxybutyrate) in fresh capillary whole blood from the finger. The FORA ADVANCED GD40 is intended for in vitro diagnostic use and is intended for single-patient use as an aid to monitor the effectiveness of a diabetes control program. The system should not be used for the diagnosis of or screening for diabetes. FORA ADVANCED GD40 Blood Glucose Test Strips are for use with the FORA ADVANCED GD40 Blood Glucose and β-Ketone Meter to quantitatively measure glucose in fresh capillary whole blood samples drawn from the finger. The FORA ADVANCED GD40 Blood β-Ketone Test Strips are for use with the FORA ADVANCED GD40 Blood Glucose and β-Ketone Meter to quantitatively measure β-ketone in fresh capillary whole blood samples drawn from the finger. β-Ketone Control Solutions are intended for use with FORA ADVANCED GD40 Blood Glucose and β-Ketone Monitoring System as a quality control check to verify the accuracy of blood ketone test results. 2 {2} 3 # FORA ADVANCED GD40 pro Blood Glucose and β-Ketone Monitoring System System is intended for the quantitative measurement of glucose in fresh capillary whole blood from the finger, and from venous, and neonatal whole blood, and for the quantitative measurement of β-ketone (beta-hydroxybutyrate) in fresh capillary whole blood from the finger, and from venous whole blood. The FORA ADVANCED GD40 pro is intended for in vitro diagnostic use and is intended for multiple-patient use in professional healthcare settings as an aid to monitor the effectiveness of a diabetes control program. This system should only be used with single-use, auto-disabling lancing devices. The system should not be used for the diagnosis of or screening for diabetes. FORA ADVANCED GD40 pro Blood Glucose Test Strips are for use with the FORA ADVANCED GD40 pro Blood Glucose and β-Ketone Meter to quantitatively measure glucose in fresh capillary whole blood samples drawn from the fingertips, and from venous and neonatal whole blood. The FORA ADVANCED GD40 pro Blood β-Ketone Test Strips are for use with the FORA ADVANCED GD40 pro Blood Glucose and β-Ketone Meter to quantitatively measure β-ketone in fresh capillary whole blood samples drawn from the fingertips and from venous whole blood. β-Ketone Control Solutions are intended for use with FORA ADVANCED GD40 pro Blood Glucose and β-Ketone Monitoring System as a quality control check to verify the accuracy of blood ketone test results. 3. Special conditions for use statement(s): For the FORA ADVANCED GD40 Blood Glucose and β-Ketone Monitoring System: - For in vitro diagnostic use (for use outside of the body only). - For single use only. - For single-patient use only. - The system should not be used for the diagnosis of or screening for diabetes. - This system is not for use in patients with abnormally low blood pressure or those who are in shock. - This system is not for use in patients in hyperglycemic-hyperosmolar state, with or without ketosis. - This system should not be used on critically ill patients. - This system should not be used on patients with impaired peripheral circulation, severe dehydration as a result of diabetic ketoacidosis or severe hyperglycemia, hyperosmolar non-ketotic coma or shock. - Neonatal Use: These test strips are not for use with neonates. - Altitude Effects: This device has not been evaluated at altitudes above 10,742 feet above sea level {3} For the FORA ADVANCED GD40 pro Blood Glucose and β-Ketone Monitoring System: - For in vitro diagnostic use (for use outside of the body only). - For single use only. - This system should only be used with single-use, auto-disabling lancing devices. - The system should not be used for the diagnosis of or screening for diabetes. - This system is not for use in patients with abnormally low blood pressure or those who are in shock. - This system is not for use in patients in hyperglycemic-hyperosmolar state, with or without ketosis. - This system has not been evaluated on critically ill patients. - This system should not be used on patients with impaired peripheral circulation, severe dehydration as a result of diabetic ketoacidosis or severe hyperglycemia, hyperosmolar non-ketotic coma or shock. - Altitude Effects: This device has not been evaluated at altitudes above 10742 feet above sea level 4. Special instrument requirements: FORA ADVANCED GD-40 Blood Glucose and β-Ketone meter FORA ADVANCED GD-40 pro Blood Glucose and β-Ketone meter I. Device Description: The FORA ADVANCED GD-40 and FORA ADVANCED GD-40 pro Blood Glucose and β-Ketone Monitoring Systems each consist of a meter, glucose and ketone test strips, and glucose and ketone control solutions (3 levels for glucose and 2 levels for ketone) sold separately. The FORA Glucose Control Solutions for glucose monitoring were previously cleared in k093724. The β-Ketone Control Solutions are new. J. Substantial Equivalence Information: 1. Predicate device name(s): Nova Max Plus Blood Glucose and β-Ketone Monitor System 2. Predicate 510(k) number(s): K091547 {4} 3. Comparison with predicate: | Similarities and Differences | | | | --- | --- | --- | | Item | Candidate Device FORA ADVANCED GD-40 and GD40 pro Blood Glucose and β-Ketone Monitoring Systems k161738 | Predicate Device Nova Max Plus Blood Glucose and β-Ketone Monitor System K091547 | | Intended Use | For the quantitative measurement of glucose and β-ketone in whole blood | same | | Sample type | Capillary whole blood from the finger, venous and neonatal whole blood | Capillary whole blood from the finger, palm and forearm | | Glucose measuring range | 20-600 mg/dL single patient 10-600 mg/dL multiple patient | 20-600 mg/dL | | β-Ketone measuring range | 0.1 – 8.0 mmol/L | same | | methodology | Glucose dehydrogenase β-hydroxybutyrate dehydrogenase | same | | Sample size | 0.9 uL glucose 1.0 uL ketone | 0.3 uL glucose 0.8 uL ketone | | Hematocrit range | 20-70% | 25-60% | | Operating conditions | 10-40°C, 10-85% RH | 14-40°C, 10-90% RH | | Reaction time | Glu = 5 seconds β-Ketone = 10 seconds | same same | | Data storage | 1000 events | 400 events | | Similarities and differences of the ketone control solution | | | | --- | --- | --- | | | Candidate Device β-Ketone Control Solutions k161738 | Predicate Device Nova Max Plus Ketone Control Solutions k091547 | | Intended use/Indications for Use | Used to check that the meters and ketone test strips are working together properly and that the test is performing correctly. | Used as a quality control check to verify the accuracy of blood ketone test results | {5} | Matrix | Water, buffer, salts, viscosity modifier, β-hydroxybutyrate, preservatives, dyes | same | | --- | --- | --- | | Levels | Levels 1 and 2 | Levels 1, 2, and 3 | # K. Standard/Guidance Document Referenced (if applicable): CLSI EP05-A2, Evaluation of Precision Performance of Quantitative Measurement Methods; Approved Guideline-Second Edition CLSI EP6-A, Evaluation of the Linearity of Quantitative Measurement Procedures: A Statistical Approach; Approved Guideline CLSI EP07-A2, Interference Testing in Clinical Chemistry; Approved Guideline - Second Edition IEC 60601-1-2, Medical electrical equipment- part 1-2: general requirements for basic safety and essential performance - collateral standard: electromagnetic compatibility - requirements and tests IEC 62304, Medical device software - software life cycle processes ISO 14971:2007, Medical Devices - Application of Risk Management to Medical Devices # L. Test Principle: Glucose measurement is based on electrochemical biosensor technology using the enzyme glucose dehydrogenase to catalyze the formation of gluconolactone from the oxidation of glucose whereby two electrons are produced. The electrical current resulting from this enzymatic reaction is measured and correlated to glucose concentration by the meter. The magnitude of the current is proportional to the concentration of glucose in the sample. The test strip is calibrated to display the equivalent of plasma glucose values to allow comparison of results with laboratory methods. Using the same technology, $\beta$ -hydroxybutyrate ( $\beta$ -ketone) is converted by $\beta$ -hydroxybutyrate dehydrogenase and the magnitude of electrical current resulting from this enzymatic reaction is proportional to the amount of $\beta$ -hydroxybutyrate present in the sample. # M. Performance Characteristics (if/when applicable): # 1. Analytical performance: Performance testing was conducted on the FORA ADVANCED GD-40 Blood Glucose and $\beta$ -Ketone Monitoring System only. This is acceptable because the only differences between the FORA ADVANCED GD-40 and FORA ADVANCED GD-40 pro systems are the name and intended use (single-patient vs. multiple-patient use). {6} a. Precision/Reproducibility: # Repeatability # Glucose Venous blood was spiked with five different glucose concentrations (30-50, 51-110, 111-150, 151-250, and $251 - 400\mathrm{mg / dL}$ ) and tested on ten FORA ADVANCED GD-40 meters and three lots of test strips. Ten replicates were tested per meter per glucose concentration. The results from all strip lots are summarized below: | Glucose Level (mg/dL) | Lot | N | Mean (mg/dL) | SD (mg/dL) | CV (%) | | --- | --- | --- | --- | --- | --- | | 30-50 | 1 | 100 | 47.6 | 2.10 | 4.41 | | | 2 | 100 | 47.3 | 2.06 | 4.35 | | | 3 | 100 | 47.1 | 2.00 | 4.25 | | 51-110 | 1 | 100 | 92.1 | 2.62 | 2.85 | | | 2 | 100 | 91.5 | 2.90 | 3.17 | | | 3 | 100 | 92.8 | 2.80 | 3.02 | | 111-150 | 1 | 100 | 132.3 | 4.18 | 3.16 | | | 2 | 100 | 130.4 | 3.92 | 3.00 | | | 3 | 100 | 133.7 | 4.28 | 3.20 | | 151-250 | 1 | 100 | 225.9 | 7.10 | 3.15 | | | 2 | 100 | 224.3 | 6.68 | 2.98 | | | 3 | 100 | 223.5 | 6.39 | 2.86 | | 251-400 | 1 | 100 | 386.1 | 12.08 | 3.13 | | | 2 | 100 | 387.6 | 11.97 | 3.09 | | | 3 | 100 | 388.3 | 11.49 | 2.96 | # Ketones Venous blood was adjusted with three different $\beta$ -ketone concentrations (0.5, 2.5, and $5.0~\mathrm{mmol / L}$ ) and tested on ten FORA ADVANCED GD-40 meters and three lots of test strips. Ten replicates were tested per meter per glucose concentration. The results from all strip lots are summarized below: | Ketone Level (mmol/L) | Lot | N | Mean (mmol/L) | SD (mmol/L) | CV (%) | | --- | --- | --- | --- | --- | --- | | 0.5 | 1 | 100 | 0.49 | 0.057 | 11.63 | | | 2 | 100 | 0.53 | 0.067 | 12.64 | | | 3 | 100 | 0.52 | 0.063 | 12.12 | | 2.5 | 1 | 100 | 2.89 | 0.099 | 3.44 | | | 2 | 100 | 2.92 | 0.103 | 3.54 | | | 3 | 100 | 2.95 | 0.108 | 3.66 | | 5.0 | 1 | 100 | 5.01 | 0.191 | 3.82 | | | 2 | 100 | 4.98 | 0.181 | 3.64 | | | 3 | 100 | 5.00 | 0.176 | 3.53 | {7} Intermediate Precision: Glucose Intermediate Precision was evaluated using three lots of test strips and ten FORA ADVANCED GD-40 meters. Three levels of Glucose control solutions were used. For each level of control, ten replicates were taken each day for ten days, so that 100 individual measurements were generated per control level. The results from all strip lots are summarized below: | Control Level | Strip Lot | N | Mean (mg/dL) | SD (mg/dL) | CV (%) | | --- | --- | --- | --- | --- | --- | | Level 1 (30-50 mg/dL) | 1 | 100 | 48.3 | 2.22 | 4.59 | | | 2 | 100 | 48.7 | 2.14 | 4.39 | | | 3 | 100 | 48.5 | 2.16 | 4.45 | | Level 2 (96-144 mg/dL) | 1 | 100 | 131.5 | 4.48 | 3.40 | | | 2 | 100 | 130.5 | 4.80 | 3.68 | | | 3 | 100 | 132.8 | 4.58 | 3.45 | | Level 3 (280-420 mg/dL) | 1 | 100 | 330.8 | 10.93 | 3.31 | | | 2 | 100 | 331.3 | 11.47 | 3.46 | | | 3 | 100 | 332.0 | 11.55 | 3.48 | Ketones | Control Level | Strip Lot | N | Mean (mmol/L) | SD (mmol/L) | CV (%) | | --- | --- | --- | --- | --- | --- | | Level 1 | 1 | 100 | 0.586 | 0.057 | 9.71 | | | 2 | 100 | 0.582 | 0.058 | 9.88 | | | 3 | 100 | 0.583 | 0.059 | 10.07 | | Level 2 | 1 | 100 | 2.588 | 0.071 | 2.76 | | | 2 | 100 | 2.598 | 0.074 | 2.84 | | | 3 | 100 | 2.591 | 0.071 | 2.75 | b. Linearity/assay reportable range: Linearity for both analytes was evaluated using three lots of test strips and five FORA ADVANCED GD-40 meters. For glucose, 10 venous whole blood samples were spiked with glucose to the following glucose concentrations: 8, 45, 70, 115, 169, 298, 386, 494, 577 and 699 mg/dL. Each glucose level was analyzed 15 times, with 5 measurements per test strip lot. For ketones, 6 venous samples were supplemented with β-ketone concentrations to the following β-ketone concentrations: <0.2, 0.5, 1.0, 2.0, 4.0, and 8.0 mmol/L. Linear regression analysis for each lot compared to results obtained using YSI for glucose and β-Hydroxybutyrate LiquiColor analyzer for ketones resulted in the following: {8} 9 ## Glucose Lot 1: $y = 1.006x + 2.406; R2 = 0.998$ Lot 2: $y = 1.0027x - 0.332; R2 = 0.998$ Lot 3: $y = 1.0034x + 0.104; R2 = 0.998$ ## Ketone Lot 1: $y = 0.9865x + 0.0058; R2 = 0.9966$ Lot 2: $y = 0.9925x + 0.0292; R2 = 0.9973$ Lot 3: $y = 0.9998x - 0.0017; R2 = 0.9981$ The results of the study support the sponsor’s claimed glucose measurement range of $20-600\ \mathrm{mg/dL}$ for the GD40 system and $10-600\ \mathrm{mg/dL}$ for the GD40 pro system, and claimed ketone measurement range of $0.1-8.0\ \mathrm{mmol/L}$ for both systems. The meters display ‘Lo’ when samples are below the measuring range and ‘Hi’ when samples are above the measuring range for both glucose and ketones. Validation testing was performed demonstrating that these feature function as intended. ## c. Traceability, Stability, Expected values (controls, calibrators, or methods): The FORA ADVANCED GD-40 and FORA ADVANCED GD-40 pro systems are traceable to the NIST SRM 917c glucose reference material and to an in-house standard prepared gravimetrically from commercially available materials for the $\beta$-ketone. The method comparison study was performed using the YSI 2300 Glucose analyzer and the $\beta$-Hydroxybutyrate LiquiColor analyzer as the reference methods (see Section M.2.a.) ## Test strip stability: ### Glucose Open and closed vial stability for the FORA ADVANCED GD-40 and FORA ADVANCED GD-40 pro Blood Glucose Test Strips were assessed in real-time studies. Study protocols and acceptance criteria were reviewed and found acceptable to support the sponsor’s claimed closed vial (shelf life) stability of 21 months, and open vial stability of 6 months when stored under the recommended storage conditions of $36^{\circ}\mathrm{F}$ to $90^{\circ}\mathrm{F}$ $(2-32^{\circ}\mathrm{C})$ and relative humidity of $10-85\%$. ### Ketone Open and closed vial stability for the FORA ADVANCED GD-40 and FORA ADVANCED GD-40 pro Blood $\beta$-Ketone Test Strips were assessed in real-time studies. Study protocols and acceptance criteria were reviewed and found acceptable to support the sponsor’s claimed closed vial (shelf life) stability of 18 months, and open vial stability of 6 months when stored under the recommended storage conditions of $36^{\circ}\mathrm{F}$ to $90^{\circ}\mathrm{F}$ $(2-32^{\circ}\mathrm{C})$ and relative humidity of $10-85\%$. {9} The FORA ADVANCED GD-40 and FORA ADVANCED GD-40 pro Blood β-Ketone Test Strips are also provided in individual foil packages. The shelf life stability of the foil packaged test strips was assessed in a real-time study. The study protocol and acceptance criteria were reviewed and found acceptable to support the sponsor’s claimed stability of 18 months when stored under the recommended storage conditions of 36°F to 90°F (2-32°C) and relative humidity of 10-85%. ## Control solution stability: ### Glucose The FORA Glucose Control Solutions were previously cleared (k093724). The stability protocols and acceptance criteria were reviewed under k093724 and found to be acceptable to support the claims that the closed control solution vials are stable for 24 months and the open control solution vials are stable for 90 days after opening when stored at the recommended storage conditions of 36°F-86°F (2°C-30°C). ### Ketone Open and closed vial stability protocols and acceptance criteria for the β-Ketone Control Solutions were reviewed and found to be acceptable to support closed vial stability of 24 months and open vial stability of 3 months when stored at the recommended storage conditions of 2-8°C. ## Value assignment of controls: ### Glucose The FORA Glucose Control Solutions were previously cleared (k093724) and are identical except in name. The value assignment protocol were reviewed under k093724 and found to be acceptable. ### Ketone Three targeted concentrations of the β-Ketone Control Solutions are prepared gravimetrically and analyzed using the YSI 2300 STAT Plus. Each level of the control solution is tested 25 times. The mean along with SD and CV are used to establish the ranges for each level which are then provided on the test strip vial label. ### d. Detection limit: The glucose measuring range is 20-600 mg/dL for the GD40 device and 10-600 mg/dL for the GD40 pro device, and the ketone measuring range is 0.1-8.0 mmol/L for both. These ranges are validated via the linearity study. See section M.1.b. 10 {10} # e. Analytical specificity: # Glucose Interference testing was performed to evaluate exogenous and endogenous substances using venous blood spiked to two glucose levels of 75 and $170\mathrm{mg / dL}$ . The samples were divided into 2 aliquots: control (with no added interferent) and test (with added interferent at a toxic level or 10 times the known therapeutic level). Each sample was measured by the reference method (YSI) and four FORA ADVANCED GD-40 meters. The sponsor defines no significant interference as bias $< \pm 10\%$ for the test compared to control samples. The following table lists the concentrations of each substance at which no significant interference was detected. | Substance | Highest concentration tested at which no significant interference is observed (mg/dL) | | --- | --- | | Acetylsalicylic acid | 50 | | Acyclovir | 3.1 | | Allopurinol | 5 | | Amitriptyline | 0.27 | | Amoxicillin | 12.5 | | Ampicillin | 5 | | Aspirin | 60 | | Atenolol | 10 | | Bicarbonate | 336 | | Caffeine | 10 | | Calcium | 5mM | | Ceftriaxone | 250 | | Chloride | 140mM | | Cholesterol | 500 | | Cholic acid | 6 | | Clonidine | 2 | | Creatinine | 30 | | Digoxin | 0.16 | | Diphenhydramine | 1 | | Enalapril | 0.15 | | Ephedrine HCl | 50 | | Erythromycin | 20 | | Estrone | 0.1 | | Famotidine | 0.13 | | Fluoxetine | 0.8 | | Folic Acid | 13.3 | | Fructose | 1000 | | Furosemide | 2 | {11} | Substance | Highest concentration tested at which no significant interference is observed (mg/dL) | | --- | --- | | Galactose | 1000 | | Gamma-Globulin | 12000 | | Gentisic acid | 2 | | Glyburide | 1.07 | | Glycerol | 1000 | | Hemoglobin | 500 | | Ibuprofen | 55 | | Icodextrin | 2000 | | Isomalt | 1000 | | Lactose | 1000 | | Lactitol | 1000 | | Lidocaine | 6 | | Magnesium | 5mM | | Maltose | 1000 | | Metaproterol | 1.81 | | Metformin HCl | 50 | | Metoprolol | 0.3 | | Naproxen | 100 | | Nifedipine | 0.17 | | Nortriptyline | 0.15 | | Penicillin | 12 | | Phenytoin | 10 | | Piroxicam | 5 | | Potassium | 10mM | | Sodium | 200mM | | Sorbitol | 1000 | | Sulfamethoxazole | 120 | | Sulfate | 5mM | | Terfenadine | 0.45 | | Tetracycline | 10 | | Theophylline | 25 | | Tolbutamide | 64 | | Trimethoprim | 12.5 | | Urea | 600 | | Vancomycin | 25 | | Verapamil | 0.45 | | Vitamin E | 20 | | Warfarin | 2 | | Xylitol | 1000 | 12 {12} The following table lists the concentrations of substances at which interference was greater than $10\%$ . | Substance | Lowest Concentration above which interference ≥10% is observed (mg/dL) | | --- | --- | | Acetaminophen | 6.25 | | Ascorbic acid | 5 | | Bilirubin | 20 | | Dopamine | 1.25 | | Levo-dopa | 0.7 | | Mannitol | 0.013 | | Mannose | 1.15 | | Methyl-dopa | 0.625 | | Reduced Glutathione | 30 | | Pralidoxime Iodide | 5 | | Tolazamide | 6.25 | | Triglycerides | 3000 | | Uric acid | 10 | | Xylose | 6.25 | To address potential interference from acetaminophen $\geq 6\mathrm{mg / dL}$ and uric acid $\geq 10\mathrm{mg / dL}$ , the labeling contains the following statements: Acetaminophen in your blood $>6.25\mathrm{mg / dL}$ might affect the reliability of your blood glucose results. If you are taking Tylenol your glucose results may not be reliable. If you are unsure, then ask your doctor. If you have a disease or condition that elevates your blood uric acid level $(>10\mathrm{mg / dL})$ , such as gout, your blood glucose results may not be reliable. If you are unsure, then ask your doctor # Ketone Interference testing was performed to evaluate exogenous and endogenous substances using venous blood spiked to two $\beta$ -Ketone levels of 1.0 and $3.0~\mathrm{mmol / L}$ . The samples were divided into 2 aliquots: control (with no added interferent) and test (with added interferent at a toxic level or 10 times the known therapeutic level). Each sample was measured by the $\beta$ -Hydroxybuturate LiquiColor analyzer and four FORA ADVANCED GD-40 meters. The sponsor defines no significant interference as bias $< \pm 10\%$ for the test compared to control samples. The following table lists the {13} concentrations of each substance at which no significant interference was detected: | Substance | Highest concentration tested at which no significant interference is observed (mg/dL) | | --- | --- | | Acetoacetate | 20.4 | | Acetone | 69.6 | | Acetylsalicylic acid | 50 | | Acyclovir | 3.1 | | Allopurinol | 5 | | Amitriptyline | 0.27 | | Amoxicillin | 12.5 | | Ampicillin | 5 | | Aspirin | 60 | | Atenolol | 10 | | Bicarbonate | 336 | | Caffeine | 10 | | Calcium | 5mM | | Chloride | 140mM | | Cholic acid | 6 | | Clonidine | 2 | | Creatinine | 5 | | Digoxin | 0.16 | | Diphenhydramine | 1 | | Enalapril | 0.15 | | Ephedrine HCl | 60 | | Erythromycin | 20 | | Estrone | 0.1 | | Famotidine | 0.13 | | Fluoxetine | 0.8 | | Fructose | 1000 | | Furosemide | 2 | | Gamma-Globulin | 12000 | | Glyberide | 1.07 | | Ibuprofen | 55 | | Isomalt | 1000 | | Lactose | 1000 | | Lactitol | 1000 | | Lidocaine | 6 | | Magnesium | 5mM | | Maltitol | 1000 | | Maltose | 1000 | | Mannitol | 1000 | | Metaproterol | 1.81 | {14} The following table lists the concentrations of substances at which interference was greater than $10\%$ . | Substance | Lowest Concentration above which interference ≥10% is observed (mg/dL) | | --- | --- | | Ascorbic acid | 4 | | Captopril | 500 | | Cholestrol | 500 | | Dopamine | 0.09 | | Gentisic acid | 1.8 | | Levo-dopa | 0.6 | | N-acetlycysteine | 2.59 | | Paracetamol | 25 | | Triglycerides | 1500 | | Uric acid | 24 | | Unconjugated bilirubin | 20 | | Prothrombin | 10 | | Thrombin | 10 | | Thrombin | 10 | | Thrombin | 10 | | Tetracycline | 10 | | Tetracycline | 10 | | Tetracycline | 10 | | Tetracycline | 10 | | Tetracyclines | 10 | | Tetracyclines | 10 | | Tetracyclines | 10 | | Tetracyclines | 10 | | Tetracyclines | 10 | | Tetracyclines | 10 | | Tetrahydrochloride | 10 | | Tetracyclines | 10 | | Tetracyclines | 10 | | Tetracyclines | 10 | | Tetracyclines | 10 | | Tetracyclines | 10 | | Tetracyclines | 10 | {15} f. Assay cut-off: Not applicable ## 2. Comparison studies: a. Method comparison with predicate device: ### Glucose System accuracy for glucose was assessed in a study using six FORA ADVANCED GD-40 meters and three lots of FORA ADVANCED GD-40 Blood Glucose test strips. Results from the meter were compared to results from the YSI analyzer. Capillary samples from the finger and sodium heparinized venous samples from 172 participants were collected. The total glucose concentration range of capillary samples tested was 43 - 512 mg/dL and total glucose concentration range of venous samples was 44-514 mg/dL. To achieve glucose concentrations less than 50 mg/dL, 6 finger and venous samples were allowed to glycolyze. To achieve glucose concentrations greater than 400 mg/dL, 4 finger and venous samples were spiked. Results of the meter measurements relative to YSI are summarized below: ### Capillary- Glucose concentration <75 mg/dL | Within ±5 mg/dL | Within ±10 mg/dL | Within ±15 mg/dL | | --- | --- | --- | | 18/33 (54.5%) | 28/33 (84.8%) | 33/33 (100%) | Glucose concentration ≥75 mg/dL | Within ±5% | Within ±10% | Within ±15% | Within ±20% | | --- | --- | --- | --- | | 85/139 (61.2%) | 121/139 (87.1%) | 136/139 (97.8%) | 139/139 (100%) | ### Venous- Glucose concentration <75 mg/dL | Within ±5 mg/dL | Within ±10 mg/dL | Within ±15 mg/dL | | --- | --- | --- | | 32/36 (88.9%) | 36/36 (100.0%) | 36/36 (100%) | Glucose concentration ≥75 mg/dL | Within ±5% | Within ±10% | Within ±15% | Within ±20% | | --- | --- | --- | --- | | 105/136 (77.2%) | 129/136 (94.9%) | 136/136 (100%) | 136/136 (100%) | Linear regression analyses results are summarized below: capillary $y = 0.9800x - 0.859, R^2 = 0.9863$ venous $y = 0.993x - 1.443, R^2 = 0.9894$ {16} # Ketone System Accuracy for $\beta$ -Ketone was assessed in a study using six FORA ADVANCED GD-40 meters and three lots of FORA ADVANCED GD-40 $\beta$ -Ketone test strips. Results from the meter were compared to results from the $\beta$ -Hydroxybutyrate LiquiColor analyzer. Capillary samples from the finger and sodium heparinized venous samples from of 120 participants were collected. The total range of capillary samples tested was $0.11 - 6.77 \mathrm{mmol} / \mathrm{L}$ and total range of venous samples was $0.04 - 5.59 \mathrm{mmol} / \mathrm{L}$ . Results of the meter measurements relative to the comparator method are summarized below: # Capillary- Ketone concentration $< 2\mathrm{mmol / L}$ | Within ±3 mmol/L | Within ±5 mmol/L | | --- | --- | | 84/89 (94.4%) | 89/89 (100%) | Ketone concentration $\geq 2\mathrm{mmol / L}$ | Within ±5% | Within ±10% | Within ±15% | Within ±20% | Within ±25% | | --- | --- | --- | --- | --- | | 13/31(41.9%) | 26/31(83.9%) | 29/31 (93.5%) | 31/31 (100%) | 31/31 (100%) | Venous- Ketone concentration $< 2\mathrm{mmol / L}$ | Within ±3 mmol/L | Within ±5 mmol/L | | --- | --- | | 87/89 (97.8%) | 89/89 (100%) | Ketone concentration $\geq 2\mathrm{mmol / L}$ | Within ±5% | Within ±10% | Within ±15% | Within ±20% | Within ±25% | | --- | --- | --- | --- | --- | | 15/31(48.4%) | 27/31 (87.1%) | 31/31 (100%) | 31/31(100%) | 31/31 (100%) | Results of the linear regression analyses are as follows: capillary $y = 0.975x - 0.0283, R^2 = 0.9758$ venous $y = 0.988x - 0.0187, R^2 = 0.9833$ # Neonatal Capillary heelstick To assess the glucose performance of the FORA ADVANCED GD-40 system with neonatal capillary heelstick, the sponsor performed a study with a total of 364 neonates under 28 days old. 199 capillary heelstick samples were obtained. The samples ranged from $19.6 - 121\mathrm{mg / dL}$ as measured by YSI. The results are summarized in the tables below: {17} # Capillary Heelstick Glucose concentration $< 75\mathrm{mg / dL}$ | Within ±5 mg/dL | Within ±10 mg/dL | Within ±15 mg/dL | | --- | --- | --- | | 57/116 (49.1%) | 102/116 (87.9%) | 115/116 (99.1%) | Glucose concentration $\geq 75\mathrm{mg / dL}$ | Within ±5% | Within ±10% | Within ±15% | Within ±20% | | --- | --- | --- | --- | | 42/83 (50.6%) | 68/83 (81.9%) | 81/83 (97.6%) | 83/83 (100%) | Results of the linear regression analyses are as follows: Capillary $y = 0.9154x + 7.413, R^2 = 0.9613$ b. Matrix comparison: Not applicable # 3. Clinical studies: a. Clinical Sensitivity: Not applicable b. Clinical specificity: Not applicable c. Other clinical supportive data (when a. and b. are not applicable): # Glucose To assess the glucose performance of the FORA ADVANCED GD-40 system in the hands of the intended users the sponsor performed a study with 160 diabetic lay user participants. Participants obtained and tested their own fingerstick samples with the FORA ADVANCED GD-40 system. Blood glucose results from the GD-40 meter obtained by the lay user were compared to the YSI reference value. The samples ranged from 49 to $520\mathrm{mg / dL}$ as measured by YSI. The results are summarized in the tables below: Glucose concentration $< 75\mathrm{mg / dL}$ | Within ±5 mg/dL | Within ±10 mg/dL | Within ±15 mg/dL | | --- | --- | --- | | 22/33 (66.7%) | 32/33 (97%) | 33/33 (100%) | {18} Glucose concentration $\geq 75\ \mathrm{mg/dL}$ | Within ±5% | Within ±10% | Within ±15% | Within ±20% | | --- | --- | --- | --- | | 100/127 (78.7%) | 122/127 (96.1%) | 125/127 (98.4%) | 127/127 (100%) | Results of the linear regression analysis: $$ y = 0.9683x + 6.057, \ R^2 = 0.975 $$ ## Ketone To assess the ketone performance of the FORA ADVANCED GD-40 system in the hands of the intended users the sponsor performed a study with 120 lay user participants. Participants obtained and tested their own fingerstick samples with the FORA ADVANCED GD-40 system. $\beta$-Ketone results from the GD-40 meter obtained by the lay user were compared to the $\beta$-Hydroxybutyrate LiquiColor analyzer. The samples ranged from 0.04 to $6.77\ \mathrm{mmol/L}$. Results of the meter measurements relative to the comparator method are summarized below: Ketone concentration $< 2\ \mathrm{mmol/L}$ | Within ±3 mmol/L | Within ±5 mmol/L | | --- | --- | | 80/89 (89.9%) | 89/89 (100%) | Ketone concentration $\geq 2\ \mathrm{mmol/L}$ | Within ±5% | Within ±10% | Within ±15% | Within ±20% | Within ±25% | | --- | --- | --- | --- | --- | | 15/31 (48.4%) | 25/31 (80.6%) | 30/31 (96.8%) | 30/31 (96.8%) | 31/31 (100%) | Results of the linear regression analysis: $$ y = 1.019x - 0.043, \ R^2 = 0.979 $$ 4. Clinical cut-off: Not applicable 5. Expected values/Reference range: The fasting adult blood glucose range for a person without diabetes¹: - Before meals $< 100\ \mathrm{mg/dL}$ (5.6 mmol/L) - After meals: $< 140\ \mathrm{mg/dL}$ (7.8 mmol/L) ¹American Diabetes Association: Standards of medical care in diabetes (2016). Diabetes Care, Vol 39, Supplement 1, S16. {19} 20 N. Instrument Name: FORA ADVANCED GD-40 Blood Glucose and β-Ketone Meter FORA ADVANCED GD-40 pro Blood Glucose and β-Ketone Meter O. System Descriptions: 1. Modes of Operation: Does the applicant’s device contain the ability to transmit data to a computer, webserver, or mobile device? Yes ☐ x ☐ or No ☐ Does the applicant’s device transmit data to a computer, webserver, or mobile device using wireless transmission? Yes ☐ x ☐ or No ☐ 2. Software: FDA has reviewed applicant’s Hazard Analysis and software development processes for this line of product types: Yes ☐ x ☐ or No ☐ 3. Specimen Identification: There is no sample identification function with this device. Samples are applied directly to the test strip as they are collected. 4. Specimen Sampling and Handling: The device is intended to be used with capillary whole blood from the finger, venous whole blood, and neonatal capillary heelstick and venous whole blood. The whole blood sample is applied directly to the test strip by capillary action therefore there are no special handling or storage issues. 5. Calibration: Coding is necessary for β-Ketone, but not for glucose. A code strip is provided and the user is instructed to calibrate every time a new vial of ketone test strips is begun. 6. Quality Control: The sponsor provides 3 levels of FORA Glucose Control Solutions and 2 levels of β- {20} Ketone Control Solutions, all sold separately. The outer kit box labels state that controls are necessary but not included and must be purchased separately. P. Other Supportive Instrument Performance Characteristics Data Not Covered In The "Performance Characteristics" Section above: 1. Altitude study: An altitude study was performed in a glove box to simulate 3 different altitudes (0, 5000 and 15000 feet). Venous whole blood was spiked to achieve seven glucose concentrations (65, 110, 185, 275, 380, 465, and 580 mg/dL) and five ketone levels (0.2, 1.0, 3.0, 6.0, and 8.0 mmol/L). Each sample was tested with 4 meters and the glucose results were compared to YSI and the ketone results to β-Hydroxybutyrate LiquiColor. The results demonstrate acceptable bias to support the claims that altitudes up to 10,742 feet have no significant effect on blood glucose or ketone measurements with these systems. 2. Hematocrit study: The effect of different hematocrit levels were evaluated using venous whole blood samples with hematocrit levels of 20%, 30%, 40%, 50%, 60%, and 75%. Five samples were spiked to glucose concentrations of 57, 125, 236, 389, and 565 mg/dL, as measured by YSI, and four samples were spiked to β-ketone levels of 1.0, 2.8, 4.7 and 7.0 mmol/L, as measured by the β-Hydroxybutyrate LiquiColor method. The samples were tested with 6 meters and the results were compared to YSI and the normal 40% hematocrit. The % biases relative to YSI were acceptable within the claimed hematocrit range and support the claimed hematocrit range of 20 to 60%. The sponsor conducted an additional hematocrit evaluation with 22 neonate capillary blood samples with glucose concentrations ranging from 10-50 mg/dL and hematocrit levels from 50 - 65%. The data demonstrates no affect from high hematocrit levels at low glucose concentrations, as is expected to occur in the neonatal population. The data supports the claimed hematocrit range from 20-60%. 3. Infection control studies: The FORA ADVANCED GD-40 meter is intended for single-patient use, and the FORA ADVANCED GD-40 pro meter is intended for multiple-patient use. Disinfection efficacy studies were performed on the materials comprising the meters by an outside commercial laboratory service to demonstrate complete inactivation of hepatitis B virus (HBV) with Micro-Kill Wipes (EPA Reg. No. 59894-10-37549). Robustness studies were performed by the sponsor demonstrating that there was no change in performance or in external materials of the meters after 10,950 cleaning and disinfection cycles with Micro-Kill Wipes. The robustness studies were designed to simulate 3 years of multiple-patient use and 5 years of single-patient use. Labeling was reviewed for adequate instructions for the validated cleaning and disinfection procedures. 4. Sample volume study: A sample volume study was performed using venous whole blood samples. Three samples were spiked to glucose concentrations of 39 mg/dL, 133 mg/dL and 325 mg/dL, as measured by YSI, to evaluate the effect of different sample volumes (0.7 μL, 0.8 μL, 0.9 μL, 1.0 μL, 1.1 μL, and 1.2 μL) on the glucose 21 {21} performance of the device. Three samples were spiked to β-Ketone levels of 0.5, 2.0, and 4.0 mmol/L, as measured by the β-Hydroxybutyrate LiquiColor method, to evaluate the effect of different sample volumes (0.8, 0.9, 1.0, 1.1, 1.2, and 1.3 mmol/L) on the β-Ketone performance of the device. Three lots of test strips and 5 meters were used. Results from these studies support the claimed minimum sample volume of 0.9 μL for glucose and 1.0 μL for β-Ketone. The meter displays an error message (E-F) for both analytes when an insufficient amount of blood sample is applied. The sponsor provided adequate validation for this error message. 5. Operating Temperature and Humidity: Operating temperature and humidity conditions were evaluated using four meters and three lots of glucose and ketone test strips with venous whole blood samples at three glucose concentrations (70 mg/dL, 125 mg/dL, and 320 mg/dL by YSI) and three β-Ketone levels (0.5, 2.0, and 4.0 mmol/L). The following temperature and humidity conditions were tested: 50°F (10°C)/10% RH, 50°F (10°C)/85% RH, 104°F (40°C)/10% RH, and 104°F (40°C)/85% RH. The results support the sponsor’s claimed operating temperature from 50°F to 104°F (10°C - 40°C) and relative humidity range from 10-85%. 6. EMC testing and Electrical Safety Studies: The sponsor provided documentation certifying that acceptable electromagnetic testing (EMC) had been performed and the System was found compliant. 7. Software documentation: The software documentation was reviewed and found to be acceptable. The firm provided documentation to support the device was designed, developed and is under good software lifecycle processes. 8. Readability Assessment: A Flesch-Kinkaid reading level assessment was conducted demonstrating that the user manual, test strip inserts, and control inserts were written at or below an 8th grade reading level. This device was cleared after the FDA issued final guidance documents for prescription use blood glucose monitoring systems (BGMS) and over-the-counter use blood glucose monitoring systems (SMBG). However, the recommendations in the guidance documents were not followed for this device since the submission was received prior to the finalization of the guidance documents. Q. Proposed Labeling: The labeling is sufficient and it satisfies the requirements of 21 CFR Part 809.10. R. Conclusion: The submitted information in this premarket notification is complete and supports a substantial equivalence decision.