Advanced rheumatoid arthritis (RA) is complicated by extra-articular manifestations such as small- and medium-sized vasculitis, pulmonary fibrosis, and pleurisy. The clinical course of the disease is refractory and critical. Treating advanced RA with multiple extra-articular manifestations is challenging. Here, we report a case of advanced RA in a 75-year-old man with exudative pleurisy and Felty syndrome. Treatment should be initiated promptly while paying attention to the possibility of infection as a differential diagnosis of exudative pleurisy because of the drastic change in the patient's condition due to disease progression. In addition, appropriate treatment is required to differentiate between Felty syndrome and malignant diseases. In older patients with RV complicated by pleurisy and Felty syndrome, starting steroids and immunosuppressive agents is crucial when conducting a thorough examination and considering the rapid progression of symptoms.