A primary pollution source by pharmaceuticals is hospital wastewater (HWW). Herein, the methods involved in the action of a biological system (BS, aerobic activated sludge) or a sonochemical treatment (US, 375 kHz and 30.8 W), for degrading four relevant pharmaceuticals (azithromycin, ciprofloxacin, paracetamol, and valsartan) in HWW, are shown. Before treatment of HWW, the correct performance of BS was assessed using glucose as a reference substance, monitoring oxygen consumption, and organic carbon removal. Meanwhile, for US, a preliminary test using ciprofloxacin in distilled water was carried out. The determination of risk quotients (RQ) and theoretical analyses about reactive moieties on these target substances are also presented. For both, the degradation of the pharmaceuticals and the calculation of RQ, analyses were performed by LC-MS/MS. The BS action decreased the concentration of paracetamol and valsartan by ∼96 and 86%, respectively. However, a poor action on azithromycin (2% removal) was found, whereas ciprofloxacin concentration increased ∼20%; leading to an RQ value of 1.61 (high risk) for the pharmaceuticals mixture. The analyses using a biodegradation pathway predictor (EAWAG-BDD methodology) revealed that the amide group on paracetamol and alkyl moieties on valsartan could experience aerobic biotransformations. In turn, US action decreased the concentration of the four pharmaceuticals (removals > 60% for azithromycin, ciprofloxacin, and paracetamol), diminishing the environmental risk (RQ: 0.51 for the target pharmaceuticals mixture). Atomic charge analyses (based on the electronegativity equalization method) were performed, showing that the amino-sugar on azithromycin; piperazyl ring, and double bond close to the two carbonyls on ciprofloxacin, acetamide group on paracetamol, and the alkyl moieties bonded to the amide group of valsartan are the most susceptible moieties to attacks by sonogenerated radicals. The LC-MS/MS analytical methodology, RQ calculations, and theoretical analyses allowed for determining the degrading performance of BS and US toward the target pollutants in HWW.•Biological and sonochemical treatments as useful methods for degrading 4 representative pharmaceuticals are presented.•Sonochemical treatment had higher degrading action than the biological one on the target pharmaceuticals.•Methodologies for risk environmental calculation and identification of moieties on the pharmaceuticals susceptible to radical attacks are shown.