Hypertension Treatment: Drugs vs Renal Denervation
- DeepQure
- Jul 22, 2025
- 5 min read
Hypertension is among the most significant non-communicable disease burdens globally, and affects more than 1.9 billion adults worldwide. As a leading risk factor for stroke, renal failure, and overall cardiovascular mortality, its management is a critical concern across both primary and specialty care.
Historically, hypertension’s management has centred on pharmacologic therapy, which is tailored to each patient’s risk profile and comorbidity. In recent years, however, renal denervation (RDN) has re-emerged as a viable intervention. This is particularly so for patients with resistant hypertension, a more severe condition that sees poor control of blood pressure despite being on 3 or more antihypertensive drugs.
How does RDN compare to pharmaceuticals as a therapeutic modality though?
The Default Intervention: Antihypertensive Drugs
Pharmacologic solutions for hypertension span several classes, most commonly:
Angiotensin-converting enzyme (ACE) inhibitors
Angiotensin receptor blockers (ARBs)
Thiazide diuretics
Calcium channel blockers
Beta-blockers
These medications have various mechanisms of action to lower a patient’s blood pressure including peripheral vascular resistance, fluid balance, and neurohormonal regulation. Currently, most treatment guidelines recommend a combination of at least two of these drug classes to achieve target blood pressures. Individual medications can also be escalated or substituted based on side effect profiles, patient comorbidities, and drug response. Despite the flexibility that pharmaceuticals afford, their efficacy is closely tied to long-term adherence, and real-world effectiveness is often suboptimal due to a mix of side effects, pill burden, cost barriers, and asymptomatic disease perception.
Renal Denervation: The New Paradigm
Renal denervation is a one-time procedure that ablates the nerves running along the outside of the renal arteries. Doing so disrupts the afferent and efferent (i.e. two-way) signalling between the kidneys and the sympathetic nervous system (SNS), which reduces blood pressure in patients with overactive SNSes. This is an especially promising option for patients that see limited improvements even with pharmaceuticals and lifestyle interventions. Two devices for performing renal denervation are currently approved by the FDA, although several others are under various stages of development.
Drugs vs Renal Denervation: A Comparison
Renal denervation is currently recognised as an adjunct treatment for hypertension – the primary being pharmacologic solutions, of course, as well as lifestyle interventions such as changes to a patient’s diet. As RDN’s technology continues to mature, however, it has potential to become a primary intervention for hypertensive patients. The flexibility afforded by an additional option is always welcomed, especially given the differences between RDN and pharmacologic intervention.
1. Clinical validation
Pharmacological therapy remains the most broadly validated approach for hypertension management, with various meta-analyses credibly establishing different drugs’ efficacies, side effects, and long-term impacts on cardiovascular morbidity and mortality.
RDN, on the other hand, has produced statistically significant reductions in blood pressure so far based on clinical trials. Broader, longer-term studies are still ongoing; interim findings that have been published reveal very promising results that are in line with the medical community’s expectations. More importantly, renal denervation has proven effective in addressing resistant and refractory hypertension – conditions that see uncontrolled blood pressures despite a patient being on 3 and 5 drugs respectively. On that front, RDN serves as a clinically meaningful alternative to drugs.
2. Permanence
Antihypertensive medications require lifelong adherence. Stopping a patient’s drug regimen almost invariably leads to a rebound in blood pressure unless the discontinuation of drugs is offset by major lifestyle changes.
In contrast, RDN offers sustained blood pressure reductions as nerve ablation is largely a permanent process. While nerve regrowth is technically possible, long-term follow-ups in clinical trials so far have shown lasting effects in most patients, with only a tiny minority requiring follow-up therapy.
3. Patient compliance
Antihypertensive drugs’ efficacies are highly dependent on patient adherence and proper titration. Unfortunately, adherence to antihypertensive drugs is notoriously poor, and estimates suggest that up to 50% of patients discontinue at least one medication within a year, which undermines therapeutic impact.
With RDN, patient adherence is a non-issue – once the procedure is completed, there is no need for daily actions by the patient. This improves outcomes in nonadherent populations or those with psychological or cognitive barriers to consistent medication use.
4. Safety and side effects
Antihypertensives are associated with a wide range of side effects, including electrolyte imbalances (diuretics), angioedema (ACE inhibitors), bradycardia (beta-blockers), and sexual dysfunction (multiple classes). Concurrent use of multiple medicines compounds these effects, particularly in elderly and/or comorbid patients.
RDN, as a procedural intervention, avoids systemic side effects but carries procedural risks including vascular complications and renal artery injury. Serious adverse event rates remain low at less than 1% though.
5. Regulatory approval
A wide range of antihypertensive drugs across multiple classes have been granted regulatory approval in various markets, with clear guidelines on first- and second-line use.
Renal denervation, in contrast, has seen limited recognition in terms of regulatory approvals so far. In the US, for instance, only two devices have been approved by the FDA for performing the procedure. This is set to change in the years ahead given the devices under development, as well as the ongoing clinical trials to prove their efficacies.
6. Cost and reimbursements
Drug therapy is generally less expensive upfront, especially for generics. However, long-term cumulative costs can be substantial over decades, particularly with multi-drug regimens.
RDN involves a high one-time procedural cost typically between US$5,000 and US$10,000. Long-term potential savings, however, include monetary costs for drugs, as well as time and financial costs for clinical visits. It’s worth noting that reimbursement is currently limited for renal denervation, although this too is expected to change as the procedure becomes more mainstream.
7. Adoption and market size
The antihypertensive drug market is massive. Global revenues are projected to reach US$35 billion by 2030 as ageing populations and a growing prevalence of the condition drive demand for medications worldwide.
For now, RDN occupies a niche market. This is set to expand rapidly with increasing clinical validation, reimbursement support, and broader physician awareness; various analysts project the global RDN market to reach US$2-3 billion annually within the next decade.
Conclusion: Two Sides of the Same Coin
Antihypertensive drugs and renal denervation are not mutually-exclusive. Rather, they offer valuable and increasingly complementary interventions for managing hypertension. Currently, drugs remain the primary therapy given their accessibility, flexibility, and extensive clinical evidence base. However, for the growing cohort of patients with resistant hypertension, poor drug tolerance, and/or adherence challenges, RDN is a compelling alternative that addresses the effects of a dysregulated sympathetic nervous system right at their source.
As hypertension management continues to mature as a field of study, intervention will likely grow increasingly personalised – like precision medicine elsewhere – and integrate pharmacology, device-based interventions, and behavioral strategies.
