Pharmaceutical residues in wastewater pose persistent ecological and public health risks, creating an urgent need for efficient and sustainable remediation technologies. MXene-based photocatalysts have attracted growing interest owing to their high electrical conductivity, tunable surface chemistry, abundant active sites, and excellent charge-transfer capability. This review summarizes recent advances in MXene-based photocatalytic systems for pharmaceutical wastewater treatment and renewable energy production. Key topics include pharmaceutical degradation pathways, reactive oxygen species generation, ecotoxicological implications, and the multifunctional roles of MXenes as conductive supports, electron mediators, and cocatalysts. Interfacial engineering strategies, including Z-scheme, S-scheme, and Schottky heterojunctions, are discussed with respect to light absorption, charge separation, and interfacial redox reactions. Practical considerations, such as reactor design, life cycle assessment, and techno-economic feasibility, are also addressed. Finally, current challenges and future directions are highlighted, particularly scalable fluorine-free synthesis, improved oxidative stability, and machine learning-assisted material design. This review provides a concise framework for developing stable, efficient, and scalable MXene-based photocatalytic platforms for pharmaceutical wastewater remediation and sustainable energy generation.