LaGamma EF, Kirtok N, Chan O, Nankova BB. Partial blockade of nicotinic acetylcholine receptors improves the counterregulatory response to hypoglycemia in recurrently hypoglycemic rats. Am J Physiol Endocrinol Metab 307: E580 -E588, 2014. First published August 12, 2014; doi:10.1152/ajpendo.00237.2014.-Recurrent exposure to hypoglycemia can impair the normal counterregulatory hormonal responses that guard against hypoglycemia, leading to hypoglycemia unawareness. This pathological condition known as hypoglycemia-associated autonomic failure (HAAF) is the main adverse consequence that prevents individuals with type 1 diabetes mellitus from attaining the long-term health benefits of tight glycemic control. The underlying molecular mechanisms responsible for the progressive loss of the epinephrine response to subsequent bouts of hypoglycemia, a hallmark sign of HAAF, are largely unknown. Normally, hypoglycemia triggers both the release and biosynthesis of epinephrine through activation of nicotinic acetylcholine receptors (nAChR) on the adrenal glands. We hypothesize that excessive cholinergic stimulation may contribute to impaired counterregulation. Here, we tested whether administration of the nAChR partial agonist cytisine to reduce postganglionic synaptic activity can preserve the counterregulatory hormone responses in an animal model of HAAF. Compared with nicotine, cytisine has limited efficacy to activate nAChRs and stimulate epinephrine release and synthesis. We evaluated adrenal catecholamine production and secretion in nondiabetic rats subjected to two daily episodes of hypoglycemia for 3 days, followed by a hyperinsulinemic hypoglycemic clamp on day 4. Recurrent hypoglycemia decreased epinephrine responses, and this was associated with suppressed TH mRNA induction (a measure of adrenal catecholamine synthetic capacity). Treatment with cytisine improved glucagon responses as well as epinephrine release and production in recurrently hypoglycemic animals. These data suggest that pharmacological manipulation of ganglionic nAChRs may be promising as a translational adjunctive therapy to avoid HAAF in type 1 diabetes mellitus.hypoglycemia-associated autonomic failure; tyrosine hydroxylase; epinephrine release; cytisine; partial nicotinic acetylcholine receptor agonists AN ATTENUATED SYMPATHOADRENAL RESPONSE following recurrent exposure to hypoglycemia results in a pathological inability to recover from low blood glucose levels, contributes to patient unawareness of hypoglycemia, and is associated with increased mortality in type 1 and possibly type 2 diabetic patients, a condition known as hypoglycemia-associated autonomic failure (HAAF) (1, 11). HAAF is recognized as a major public health problem for patients with diabetes. It can also be induced in healthy subjects, in infants and in animal models suggesting it may involve a maladaptive response to repeated stress (9,12,14,20).Despite the well-established role of hypoglycemia per se in the development of HAAF, the mechanism(s) underlying the key feature of t...