High expression of the chemokine receptor 4, CXCR4, associated to negative prognosis in acute myeloid leukemia, is related to hypoxia. Because CXCR4 expression is under the posttranscriptional control of microRNA-146a in normal and leukemic monocytic cells, we first investigated the impact of hypoxia on microRNA-146a and CXCR4 expression during monocytopoiesis and in acute monocytic leukemia. Then, we analyzed the effects of hypoxia on drug sensitivity of CXCR4-expressing leukemic cells. We reported that microRNA-146a is a target of hypoxia-inducible factors (HIFs)-1alpha or -2alpha in relation to the stage of monocytopoiesis and the level of hypoxia, and demonstrated the regulation of the microRNA-146a/CXCR4 pathway by hypoxia in monocytes derived from CD34+ cells. Then, in myeloid leukemic cell lines, hypoxia-mediated control of microRNA-146a/CXCR4 pathway depends only on the capacity of hypoxia-inducible factor-1alpha to upregulate microRNA-146a, which in turn decreases CXCR4 expression. However, at variance with normal monocytic cells and leukemic cell lines, in acute monocytic leukemia overexpressing CXCR4, hypoxia upmodulates microRNA-146a but fails to downmodulate CXCR4 expression. We then investigated the effect of hypoxia on the response of leukemic cells to chemotherapy treatment performed alone or in combination with stromal-derived factor-1alpha. We found that hypoxia increases stromal-derived factor-1alpha-induced survival of leukemic cells by decreasing their sensitivity to anti-leukemic drugs. Altogether, our results demonstrate that hypoxia-mediated regulation of microRNA-146a that controls CXCR4 expression in monocytic cells is lost in acute monocytic leukemia, thus contributing to maintain CXCR4 overexpression and their protection from anti-leukemic drugs in the hypoxic bone marrow microenvironment.