Hypoxia-inducible factor 1a is a key regulator of the hypoxia response in normal and cancer tissues. It is well recognized to regulate glycolysis and is a target for therapy. However, how tumor cells adapt to grow in the absence of HIF1a is poorly understood and an important concept to understand for developing targeted therapies is the flexibility of the metabolic response to hypoxia via alternative pathways. We analyzed pathways that allow cells to survive hypoxic stress in the absence of HIF1a, using the HCT116 colon cancer cell line with deleted HIF1a versus control. Spheroids were used to provide a 3D model of metabolic gradients. We conducted a metabolomic, transcriptomic, and proteomic analysis and integrated the results. These showed surprisingly that in three-dimensional growth, a key regulatory step of glycolysis is Aldolase A rather than phosphofructokinase. Furthermore, glucose uptake could be maintained in hypoxia through upregulation of GLUT14, not previously recognized in this role. Finally, there was a marked adaptation and change of phosphocreatine energy pathways, which made the cells susceptible to inhibition of creatine metabolism in hypoxic conditions. Overall, our studies show a complex adaptation to hypoxia that can bypass HIF1a, but it is targetable and it provides new insight into the key metabolic pathways involved in cancer growth.Implications: Under hypoxia and HIF1 blockade, cancer cells adapt their energy metabolism via upregulation of the GLUT14 glucose transporter and creatine metabolism providing new avenues for drug targeting. Analysis of the HCT116 hypoxic metabolic phenotype. A-C, Metabolomics-and proteomics-integrated circos-plots showing significantly regulated features only in KON versus WTN, WTH versus WTN, KOH versus KON, and KOH versus WTH (upper side circos-plots). Adjusted P < 0.05 ( Ã ) or P < 0.01 ( ÃÃ ) are indicated for the different experimental comparisons (connecting lines inside circos-plots): KON/WTN (gray/white-gray connection) WTH/WTN (gold/white-brown connection), KOH/KON (blue/gray-violet connection), KOH/WTH (blue/gold-green connection). Colored boxes (lower side circos-plots linked to connecting lines) represent different metabolic pathways, while colored boxes (inside circos-plots linked to connecting lines) identify the biological condition where the feature is upregulated. D, Heatmap of integrated transomics (proteomics and transcriptomics); mRNA and protein log 2 FC are calculated for WTH-WTN and KOH-WTH. Feature selection was based on departure from 95% confidence intervals of the linear model distribution built for each comparison (WTH-WTN and KOH-WTH). Metabolic pathways: glycogen (GLG), glycolysis (GLY), Krebs cycle (TCA), adenosine triphosphate (ATP), creatine (Cr), oxidation-reduction (REDOX), and adenosyl metabolism (ADE). E, Targeted metabolomics showing distribution of ATP, ADP, AMP, ATP/AMP, and ATP/ADP ratios in WTN, KON, WTH, and KOH cell after 24 hours in 21% and 1% O 2 . Raw intensities and ratios are shown as 0-1 normalized levels' rela...