OBJECTIVES:  This study aims to assess the trend of insulin initiation among diabetes patients from 2009 to 2013, with a particular focus on patients who initiate high daily doses (>200 units/day) of insulin. METHODS:  A retrospective analysis was conducted using UK general practice data from the clinical practice research datalink (CPRD). High dose insulin initiators (HDII) were defined based on total daily dose (TDD) >200 units/day and TDD ≤200 units/day in 6 months prior. The trend of initiators’ demographics, insulin initiation dose, and clinical characteristics were analyzed from year 2009, 2011, and 2013. RESULTS:  From 2009 to 2013, 19631 patients with diabetes were prescribed insulin (type 1: 7620, 38.8%; type 2: 12011, 61.2%). In 5 years, incidence of HDII increased from 289 to 415 (type 1: 95 to 170; type 2: 194 to 245). In 2013, the average age of HDII was 51.7 years (Type 1: 35.5 years; Type 2: 62.9 years), 58.8% were males, 77.6% from England. The average initiation insulin TDD of HDII was 248.5 units (2.8 units/kg), and 378 (91.1%) were prescribed insulin analogue. In a year following high dose insulin initiation, 29.3% HDII achieved HbA1c<7.5%, 33.1% of HDII reported HbA1c≥9%. Oral antidiabetic medication and GLP-1 were prescribed to 45.3% and 8.0% of HDII, respectively; concomitant antihypertension and lipid-lowering medications were prescribed to 79.8% and 65.1% of HDII, respectively. TDD of insulin at initiation of HDII was similar between 2009 and 2013, and less than 30% of patients achieved HbA1c<7.5% in this time period. CONCLUSIONS:  From 2009 to 2013, an increasing number of patients required high doses of insulin to control hyperglycemia. However, high concomitant non-insulin antidiabetic medication use and poor glycemic control in the follow-up year suggested that alternative intensive insulin therapy might be considered for this challenging population.