Defective counterregulatory responses (CRRs) to hypoglycemia are associated with a marked increase in the risk of severe hypoglycemia. The mechanisms leading to the development of defective CRRs remain largely unknown, although they are associated with antecedent hypoglycemia. Activation of AMP-activated protein kinase (AMPK) in the ventromedial hypothalamus (VMH) amplifies the counterregulatory increase in glucose production during acute hypoglycemia. To examine whether activation of AMPK in the VMH restores defective CRR, controlled hypoglycemia (ϳ2.8 mmol/l) was induced in a group of 24 Sprague-Dawley rats, all of which had undergone a 3-day model of recurrent hypoglycemia before the clamp study. Before the acute study, rats were microinjected to the VMH with either 5-aminoimidazole-4-carboxamide (AICAR; n ؍ 12), to activate AMPK, or saline (n ؍ 12). In a subset of rats, an infusion of H 3 -glucose was additionally started to calculate glucose turnover. Stimulation of AMPK within the VMH was found to amplify hormonal CRR and increase endogenous glucose production. In addition, analysis of tissue from both whole hypothalamus and VMH showed that recurrent hypoglycemia induces an increase in the gene expression of AMPK ␣ 1 and ␣ 2 . These findings suggest that the development of novel drugs designed to selectively activate AMPK in the VMH offer a future therapeutic potential for individuals with type 1 diabetes who have defective CRRs to hypoglycemia. Diabetes 55:1755-1760, 2006 S ingle or recurrent episodes of acute hypoglycemia in nondiabetic or type 1 diabetic (1-3) individuals are known to impair hormonal counterregulatory responses (CRRs) to a subsequent episode of hypoglycemia. Defective hormonal counterregulation to hypoglycemia is closely associated with both altered glucose thresholds for activation of the CRR and reduced symptomatic awareness of hypoglycemia, a combination of clinical syndromes that collectively have been termed hypoglycemia-associated autonomic failure (4). Defective hormonal CRR is in itself associated with a markedly increased risk of severe hypoglycemia (5).The mechanism through which recurrent hypoglycemia per se induces defective hormonal CRR remains largely unknown. Potential candidate mechanisms include alterations in key steps in the glucose-sensing pathway in the brain (6,7), increased glucose and/or alternate fuel uptake by the brain (8 -11), increases in the brain glycogen pool (12), and an effect of hypothalamopituitary axis activation (13,14). In addition, we have recently demonstrated that pharmacological activation of the serine/threonine kinase AMP-activated protein kinase (AMPK) in the ventromedial hypothalamus (VMH), a key central glucose-sensing region (15), amplifies the glucose CRR to acute hypoglycemia. In that study AMPK activation in the VMH during acute hypoglycemia resulted in a marked increase in endogenous glucose production (R a ), with a corresponding reduction in the requirement for exogenous glucose, in the absence of a change in the hormonal CRR (1...