Sulindac causes regression of and prevents recurrence of colonic adenomas in patients with familial adenomatous polyposis. Although cell cycle arrest and apoptosis have been proposed, the mechanism of action is poorly understood. In this study, we characterized the growth-inhibitory effects of active metabolites of sulindac in cultured colon adenocarcinoma cells by determining the contribution of apoptosis and cell cycle arrest and the requirement for cyclooxygenase (COX) inhibition and p53 involvement and compared the effects of sulindac metabolites with the chemotherapeutic drug, 5-fluorouracil (5-FU). Time course and dose-response experiments demonstrated that increased apoptosis paralleled the growth-inhibitory effects of the sulfide and sulfone. A relationship among a series of nonsteroidal anti-inflammatory drugs was observed between potency for growth inhibition and ability to induce apoptosis but not potency to inhibit COX. For example, the sulfone was at least 5000-fold less potent than the sulfide for inhibiting COX but only 6.5-fold less potent for inducing apoptosis. Moreover, the prostaglandin analogue, dimethyl-prostaglandin E₂, failed to reverse the apoptosis-inducing effects of the sulfide. Sulindac metabolites caused G₁ cell cycle arrest in proliferating cells but were comparably effective in nonproliferating cells. In contrast, 5-FU treatment was less effective in nonproliferating cells. Combined treatment with sulindac metabolites and 5-FU did not result in an additive apoptotic response. Treatment of cells with 5-FU increased p53 protein levels, whereas sulindac metabolites did not induce expression. Saos-2 cells, which lack p53, responded to sulindac metabolites but not 5-FU. These results show that apoptosis primarily contributes to growth inhibition by sulindac metabolites. The biochemical pathway does not require COX inhibition or p53 induction and appears to be fundamentally different from the apoptotic response to 5-FU.