About Blood Glucose Meters

According to the International Diabetes Federation, in 2017, 425 million people (20-79 years) worldwide (over 9% of the global population) are living with diabetes in 2017, and another 352 million people were at high risk of developing type 2 diabetes.

It has been estimated that one person dies from diabetes every six seconds and that 4 million deaths were caused by diabetes in 2017. Worryingly, the epidemic shows no signs of relenting, with the number of people living with diabetes expected to reach 629 million by 2045.

Clinical Accuracy of Blood Glucose Meters

Development of blood glucose meter validation

As listed below, protocols to validate blood glucose meters independently were initiated by the American Diabetes Association in 1987. Several organisations, including the FDA, the Canadian Standards Association, and the US based Clinical and Laboratory Standards Institute (or the National Committee for Clinical Laboratory Standards as it was known prior to 2005) also developed validation criteria, many of which were revised. Apart from the 2013 CLSI standard, most of these have since been either withdrawn or superseded. The ISO, in conjunction with CEN, developed a draft standard 15197 in 2000, which was finalised in 2002 and revised in 2003 and 2013. The most recent call for new validation procedures has been made by Klonoff et al in 2015. [2]

Error Grids

Error grid analysis, to quantify the potential harm of error levels in blood glucose meters for self-measurement, as against reference measurements, was first postulated by Clarke et al in 1987 with the grid, described in the paper, becoming known as the Clarke Error Grid. [3] Parkes et al. published an alternative Consensus Error Grid, also known as the Parkes Error Grid, in 2000 [4] and this now forms part of ISO 15197:2013. Klonoff et al described a Surveillance Error Grid in 2014 [5].

  1. International Diabetes Federation. IDF Diabetes Atlas, 6th Edition, 2014 Update [Internet]. Brussels: IDF; 2015 [Updated 2015 Mar 07; Cited 2015 Jul 03].
  2. Klonoff DC, Lias C, Beck S, Parkes JL, Kovatchev B, Vigersky RA, Arreaza-Rubin G, Burk RD, Kowalski A, Little R, Nichols J, Petersen M, Rawlings K, Sacks DB, Sampson E, Scott S, Seley JJ, Slingerland R, Vesper HW. Development of the Diabetes Technology Society Blood Glucose Monitor System Surveillance Protocol. J Diabetes Sci Technol. 2016 May 3;10(3):697-707. doi: 10.1177/1932296815614587. Epub 2015 Oct 18. PMID: 26481642.
  3. Clarke WL, Cox D, Gonder-Frederick LA, Carter W, Pohl SL. Evaluating clinical accuracy of systems for self-monitoring of blood glucose. Diabetes Care. 1987;10(5):622–8. doi: 10.2337/diacare.10.5.622. PMID: 3677983. Download here.
  4. Parkes JL, Slatin SL, Pardo S, Ginsberg BH. A new consensus error grid to evaluate the clinical significance of inaccuracies in the measurement of blood glucose. Diabetes Care. 2000;23(8):1143-8. doi: 10.2337/diacare.23.8.1143. PMID: 10937512. Download here.
  5. Klonoff DC, Lias C, Vigersky R, Clarke W, Parkes JL, Sacks DB, Kirkman MS, Kovatchev B; Error Grid Panel. The surveillance error grid. J Diabetes Sci Technol. 2014;8(4):658-72. doi: 10.1177/1932296814539589. PMID: 25562886. Download here.

Clinical Validation Protocols for Blood Glucose Meters

ISO/IEC/CEN/DIN
 15197:2013International Organization for Standardization Technical Committees ISO/TC 212 and ISO/TC 140. ISO 15197:2013, In vitro diagnostic test systems – Requirements for blood-glucose monitoring systems for self-testing in managing diabetes mellitus. Geneva, Switzerland: ISO; 2013. Preview available here.
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 Comité Européen de Normalisation CEN/TC 140. EN ISO 15197:2015, In vitro diagnostic test systems. Requirements for blood-glucose monitoring systems for self-testing in managing diabetes mellitus. Geneva, Switzerland: CEN; 2015 Jun 10.
DTS
 DTS:2016Klonoff DC, Lias C, Beck S, Parkes JL, Kovatchev B, Vigersky RA, Arreaza-Rubin G, Burk RD, Kowalski A, Little R, Nichols J, Petersen M, Rawlings K, Sacks DB, Sampson E, Scott S, Seley JJ, Slingerland R, Vesper HW. Development of the Diabetes Technology Society Blood Glucose Monitor System Surveillance Protocol. J Diabetes Sci Technol. 2016 May 3;10(3):697-707. doi: 10.1177/1932296815614587. PMID: 26481642. Download here
FDA
 FDA:2016PUS Department of Health and Human Services, Food and Drug Administration, Center for Devices and Radiological Health, Office of In Vitro Diagnostic Device Evaluation and Radiological Health, Division of Chemistry and Toxicology Devices. Blood Glucose Monitoring Test Systems for Prescription Point-of-Care Use – Guidance for Industry and Food and Drug Administration Staff. Rockville, Maryland, USA: FDA; 2016. Download here
 FDA:2016HUS Department of Health and Human Services, Food and Drug Administration, Center for Devices and Radiological Health, Office of In Vitro Diagnostic Device Evaluation and Radiological Health, Division of Chemistry and Toxicology Devices. Self-Monitoring Blood Glucose Test Systems for Over-the- Counter Use – Guidance for Industry and Food and Drug Administration Staff. Rockville, Maryland, USA: FDA; 2016. Download here
CLSI
 CLSI:2013Clinical and Laboratory Standards Institute. CLSI POCT12 A3 Ed. 3 (2013), Point-of-care Blood Glucose Testing in Acute and Chronic Care Facilities. Wayne, Pennsylvania, USA: CLSI; 2013.
 CLSI:2008Klonoff D, Bernhardt P, Ginsberg BH, Joseph J, Mastrototaro J, Parker DR, Vesper H, Vigersky R. CLSI POCT05-A Ed. 1 (2008), POCT05-A: Performance Metrics for Continuous Interstitial Glucose Monitoring; Approved Guideline. Wayne, Pennsylvania, USA: CLSI; 2008. Information here
Chinese Medical Association
 CMA:2016中华医学会检验医学分会 [Chinese Medical Association, Laboratory Medicine Branch]. 便携式血糖仪临床操作和质量管理规范 中国专家共识 [Portable blood glucose meter clinical operation and quality management practices – Chinese expert consensus]. 中华医学杂志 [Natl Med J China] 2016 Sep 27;96(36):2864–7. Download here

ISO/IEC/CEN/DIN
 15197:2011Межгосударственный совет по стандартизации, метрологии и сертификации. ГОСТ ISO 15197-2011, Системы диагностические in vitro. Требования к системам мониторного наблюдения за концентрацией глюкозы в крови для самоконтроля при лечении сахарного диабета. Москва, Россия: МГС; 2013. [EuroAsian Interstate Council for Standardization, Metrology and Certification GOST ISO 15197-2011, In vitro diagnostic test systems. Requirements for blood-glucose monitoring systems for self-testing in managing diabetes mellitus. Moscow, Russia: EASC; 2013.] Information here
 15197:2003International Organization for Standardization Technical Committee ISO/TC 212. EN ISO 15197:2003, In vitro diagnostic test systems — Requirements for blood-glucose monitoring systems for self-testing in managing diabetes mellitus. Geneva, Switzerland: ISO; 2003. Information here
 15197:2002International Organization for Standardization. DIN EN ISO 15197:2002, Determination of performance criteria for in vitro blood glucose monitoring systems for management of human diabetes mellitus. ISO 15197. Geneva, Switzerland: ISO; 2002.
 15197:2001International Organization for Standardization. ISO Draft International Standard 15197.2, In vitro diagnostic systems —Requirements for in vitro blood glucose monitoring systems for self-testing in managing diabetes mellitus. Geneva, Switzerland: ISO; 2001.
FDA
 FDA:1989U.S. Food and Drug Administration. Review criteria for assessment of portable invasive blood glucose monitoring in vitro diagnostic devices which use glucose oxidase, dehydrogenase, or hexokinase methodology. Silver Spring, Maryland, USA: FDA; 1989. Information here
CLSI/NCCLS
 CLSI:2002Clinical and Laboratory Standards Institute. CLSI C30 A2 Ed. 2 (2002), Point-of-care Blood Glucose Testing in Acute and Chronic Care Facilities. Wayne, Pennsylvania, USA: CLSI; 2002.
 CLSI:1994National Committee for Clinical Laboratory Standards. NCCLS C30 A:1994, Ancillary (bedside) blood glucose testing in acute and chronic care facilities. Wayne, Pennsylvania, USA: CLSI; 1994.
 CLSI:1991National Committee for Clinical Laboratory Standards. NCCLS C30 T:1991, Ancillary (bedside) blood glucose testing in acute and chronic care facilities. Wayne, Pennsylvania, USA: CLSI; 1991.
ADA
 ADA:1996American Diabetes Association. Self-monitoring of blood glucose. Diabetes Care. 1996;19(Suppl 1):S62-S66. doi: 10.2337/diacare.19.1.S62. PMID: 8689936. Information here
 ADA:1994American Diabetes Association. Self-monitoring of blood glucose. Diabetes Care. 1994;17(1):81-6. doi: 10.2337/diacare.17.1.81. PMID: 8112195. Information here
 ADA:1987American Diabetes Association. Consensus statement on self monitoring of blood glucose. Diabetes Care. 1987;10(1):95-9. doi: 10.2337/diacare.10.1.95. PMID: 3552518. Information here
CSA
 CSA:1999Canadian Standards Association. CSA Z316.4-94 (R2000), Performance Specifications for Portable Whole Blood Glucose Monitor Systems for Use in Diabetes Management. Toronto, Ontario, Canada: CSA; 1999. Information here
 CSA:1994Canadian Standards Association. CSA Z316.4-94, Performance Specifications for Portable Whole Blood Glucose Monitor Systems for Use in Diabetes Management. Mississauga, Ontario, Canada: CSA; 1994